BERKELEY 

LIBRARY 

UNIVCaSITY  OP 
CALlK)tNIA 


DISEASES  OF  THE  EYE 

AND  HOW   RECOGNIZED 


A  Series  of  Articles  on  the  More  Common 
Diseases  with  which  the  Optician  Meets  in 
His  Every-Day  Work— The  Causes,  Symp- 
toms, Diagnosis  and  Outlines  of  Treatment 


BY 

C.  W.  TALBOT,  M.  D. 


NEW  YORK 

FREDERICK   BOGER  PUBLISHING   CO. 

ONE  MAIDEN  LANE 


COPVRICHT    lyiu 
BY 

Freukkick  Bogkk  Pui;.   Co 

I  MaidI'N  Lank, 

New  York. 


Press  of 
Tin;   Oi'iuAi.    Ioii<« 


Diseases  of  the  Eye  and  How 
Recognized 


Part  I. — Diseases  of  tiik  Eye-lids'. 

The  optometrist  should  cuUivate  the  habit  of  ob- 
servation in  every  case  of  refraction  he  has  to  deal 
with.  Not  only  for  the  patient's  benefit  and  incident- 
ally the  raising-  of  one's  self  in  the  estimation  of  the 
l)atient,  but  because  so  much  can  be  learned  of  the 
condition  by  simple  inspection.  You  can  tell  whether 
or  not  the  condition  is  a  normal  one  or  an  abnormal 
one,  and  the  early  diagnosis  of  any  eye  disease,  will  if 
promptly  treated,  insure  more  speedy  and  complete 
cure  which  reflects  on  the  optometrical  profession  and 
raises  it  in  the  eyes  of  the  public. 

There  can  be  no  fixed  rule  for  conducting  an  exam- 
ination of  the  eye,  since  in  many  cases  to  follow  a 
routine  method  would  not  only  be  a  waste  of  the  op- 
tician's time  but  the  patient's  as  well,  so  that  it  is  im- 
possible to  go  through  some  routine  procedure  in  ev- 
ery ocular  examination.  In  the  majority  of  cases  it 
will  be  found  far  safer  to  make  just  as  tJiorough  ex- 
amination as  the  time  im'll  permit. 

The  things  to  be  noticed  by  simple  inspection,  are 
the  eyes  red  or  inflamed?  are  the  margins  of  the  lids 


^S2B 


■I  DISEASES     OF     THE      EYE 

red?  arc  the  lashes  stuck  together — several  in  a  clump? 
are  the  lids  stuck  together?  is  there  any  excessive  flow 
of  tears?  any  signs  of  a  stye?  any  lump  or  "kernels" 
in  the  lid?  is  the  cornea  clear  or  hazy  and  are  there 
any  spots  on  it?  do  the  lashes  rub  the  eyeball?  do  the 
lids  turn  out  or  drooj)?  is  there  any  growth  upon  the 
eyeball  ?  All  these,  and  more,  are  common  symptoms 
to  look  for  and  if  present  can  be  readily  seen  by  sim- 
ple inspection,  just  ordinary  observation. 

We  will  first  consider  the  external  diseases  of  the 
lids,  and  the  first  will  be  inflammations,  blepbaritis  as 
it  is  called. 

The  most  common  form  is  ])lcpliaritis  marginalis 
(marginal  inflammation  of  the  lid)  or  tinea  tarsi  as 
it  is  sometimes  called;  a  very  chronic  and  trouble- 
some affection. 

Ihis  disease  has  as  its  distinguishing  features  the 
red  and  inflamed  edges,  with  more  or  less  gluing  to- 
gether of  the  lashes,  two  or  more  in  a  clump  with 
crusts  of  the  dried  secretion  forming  on  the  skin 
around  the  lashes.  If  of  long  standing  as  the  most  of 
them  are,  we  will  see  a  shining  red  surface  underneath 
when  the  crusts  are  peeled  off  which  may  take  with 
them  a  dead  lash  or  two.    See  figure  i. 

This  condition  exists  with  other  inflammatory  trou- 
l)lcs  or  alone,  and  is  found  in  all  classes  of  people, 
more  frequently  perhaps  in  that  class  of  society  in  poor 
circumstances  with  the  unsanitary  surroundings  or 
among  the  poorly  nourished  of  the  well-to-do.  Eye- 
strain is  always  associated  with  it,  which  makes  it  im- 
possible to  effect  a  complete  cure  or  pennanent  cure 
until  the  errors  of  refraction  and  the  muscular  anom- 
alies have  been  corrected. 

This  disease  does  not  as  a  rule  cause  any  incon- 
venience, except  for  the  ai)pearance  of  the  eyes,  which 


AND     now     RECOGNIZED.  S 

most  certainly  do  ndt  add  to  one's  attractiveness.  Most 
patients  have  come  to  me  more  on  account  of  the  dis- 
figurement due  to  the  reddened  border  of  the  hds, 
than  for  any  distress  they  may  have  experienced. 

It  occurs  in  both  children  and  adults,  more  com- 
mon I  have  found  in  young  adults,  high  school  pu- 
pils. 

The  disease  may  become  quite  severe  in  persons  of 
lowered  vitality,  and  under  the  crusts  show  a  raw  or 


Mai-ginalis.      Eyclnslu' 

s    Stl 

ick     Ing.-l 

licr 

rusts   on   mnrgin   of   li 

(1   an 

long   the 

las] 

bleeding  surface  \vith  the   formation  of  small  ulcers 
along  the  edges  of  the  lids. 

About  the  only  subjective  symptoms  arc  those  burn- 
ing or  smarting  with  a  feeling  of  heat  and  irritation 
which  is  always  aggravated  by  exposure  to  dust,  wind 
or  bright  light;  ordinarily,  the  patient  does  not  com- 
plain, and  as  T  say,  would  be  fairly  content  if  it  were 
not  for  the  disfiirurement. 


G  DISKASES      OF      THE      EYE 

This  disease  is  troublesome,  chronic  and  very  per- 
sistent, and  in  untreated  cases  sooner  or  later  results 
in  a  thickening  of  the  Ids  with  a  loss  of  the  lashes 
which  permits  the  entry  of  dust  and  foreign  bodies 
with  their  consequent  deleterious  effects. 

If  untreated  for  any  length  of  time,  this  disease  en- 
tails a  series  of  sequelae,  some  of  which  to  a  certain 
extent  react  upon  the  disease  itself  and  greatly  aggra- 
vate it ;  these  are  permanent  loss  of  the  lashes  from 


II.  — Stye    or   Hoicloliiini. 
ml    sIkiws   quite   ;i    •^wclliuu 


destruction  of  the  hair  follcles  through  infection  and 
suppuration,  this  not  only  greatly  disfigures  but  leaves 
the  eye  without  its  hairy  defenders  and  renders  it 
more  liable  to  injuries  from  foreign  bodies.  There 
may  be  only  a  partial  loss  of  the  lashes  and  the  re- 
maining ones  may  grow  irregularly,  scratching  the  eye- 
ball ;  this  is  due  to  the  formation  of  little  scars  forming 
at  the  site  of  the  small  ulcerations.     In  long  standing 


AND     HOW     RECOGNIZED.  7 

cases  there  is  an  inflammatory  condition  brought  about 
with  a  more  or  less  of  a  mucus  discharge,  this  is 
known  as  catarrhal  conjunctivitis  which  will  be  consid- 
ered later. 

Often  times  the  full  correction  by  glasses  alone — 
especially  if  there  is  astigmatism — will  effect  a  conv- 
pletc  cure. 


^ 

H 


Fig.  III.— Chalazion  or  cyst  of  the  Meibomian  gland.  Eye  perfectly 
normal  except  for  the  growth  or  "swelling"  in  upper  lid  which  pre- 
vents a    wide   opening   of  the   lid. 

HORDOLEUM. 

Probably  the  next  in  frequency  among  the  external 
diseases  of  the  lid  is  the  hordoleum  or  stye.  This_  is 
of  very  common  occurrence  and  a  condition  v^^ith 
which  nearly  every  one  is  familiar.  The  duration  of 
this  painful  and  troublesome  disease  is,  as  a  rule,  quite 
short,  only  a  few  days  for  a  single  stye,  but  the  afifec- 
tion  is  very  aggravating  on  account  of  the  pain  which 


8  l>ISi;.\SKS      OF      Tllli      KYE 

is  at  times  really  quite  severe,  and  the  lids  may  be 
swollen  almost  shut. 

This  painful  disease  is  common  in  people  who  have 
had  blepharitis  marginalis  and  is  due  to  an  infection 
at  the  orot  of  the  lash  (in  the  hair  follicle)  and  may 
truly  be  regarded  as  a  boil  of  the  lid. 

Early  in  the  formation  of  a  stye  we  notice  as  the 
first  thing,  the  red  lid,  which  is,  however,  distinguish- 
ed from  the  previous  disease  we  have  been  discussing 
by  the  inflammation  extended  pretty  well  over  the  en- 
tire lid  and  not  confined  to  the  margins  alone.  Now 
if  you  will  carefully  run  your  finger  lightly  over  the 
edge  of  the  lid  you  will  discover  a  swollen  spot  which 
is  especially  sensitive  to  the  touch  and  in  the  center 
of  which  you  Vv^ill  find  a  lash.  In  a  day  or  so  the  swell- 
ing at  this  point  increases  and  the  skin  becomes  tight 
and  glistening  and  soon  around  the  lash  there  appears 
a  yellowish  or  creamy  discoloration  which  sooner  or 
later  breaks  and»  allows  i)us  to  escape. 

There  is  swelling  of  the  entire  lid  (oedema)  which 
shows  a  hard  and  painful  nodule  varying  in  size  from 
a  tiny  red  elevation  to  the  size  of  a  pea,  the  point  of 
which  is  yellowish  in  color  and  if  of  several  days  du- 
ration, may,  upon  pressure  discharge  a  drop  of  pus. 
See  figure  2. 

The  treatment  depends  largely  on  the  character 
and  age  of  the  stye  and  uix)n  the  general  condition 
of  the  patient,  sometimes  they  are  lanced  and  washed 
out  witli  a  mild  antisejitic  solution,  but  the  usual  meth- 
od of  treatment  is  with  an  ointment  containing  a  mild 
mercurial  salt.  In  the  earliest  stages  of  its  forma- 
tion a  stye  may  be  absorbed  by  pulling  out  the  lash 
in  the  center  of  the  nodule,  around  which  the  stye  is 
forming. 

Styes  generally  appear  in  "crops,"  that  is,  one  after 


AND     HOW     RFXOONIZED.  9 

another  and  when-  they  so  occur  it  will  be  found  that 
they  are  almost  invariably  aggravated  hy  refractive 
errors  which  they  oftentimes  accompany,  and  in  per- 
sons subject  to  these  repeated  attacks,  it  is  difficult  to 
stop  their  formation  without  first  correcting  the  re- 
fractive errors. 

Just  how  eye-strain  acts  as  an  etiological  factor  in 
the  causation  of  certain  lid  diseases  has  never  been 
satisfactorily  explained,  yet  the  consensus  of  opinion 
is  that  it  is  one  of  the  prime  and  predisposing  causes  in 
the  production  of  many  of  these  diseases.  Most  au- 
thorities in  this  country  and  Europe  are  agreed  as  to 
the  influence  of  eye-strain  in  creating  certain  lid  as 
well  as  bulbar  diseases  and  in  the  causation  and  per- 
petuation of  many  of  the  nervous  disorders.  They 
have  arrived  at  th-s  logical  conclusion  after  the  ob- 
servation of  thousands  of  cases  and  are  well  supported 
in  their  views  by  an  abundance  of  clinical  data. 

CHALAZION. 

Next  in  order  comes  another  lid  affection  which  is 
also  attributable  to  eye-strain, — the  chalazion  (Greek- 
meaning  "hail"). 

A  chalazion  is  a  cyst  of  the  lid,  usually  the  upper 
one  and  is  due  to  the  closure  of  the  openings  of  one  of 
the  little  Meibomian  glands,  so  that  the  secretion  does 
not  drain  out  but  remains,  increasing  in  quantity. 

This  cyst  is  usually  round  and  varies  in  size,  as  a 
rule  about  the  size  of  a  pea  when  first  noticed,  it 
grows  slowly  and  causes  no  pain  or  inconvenience,  ex- 
cept it  prevents  a  wide  opening  of  the  lids  when  look- 
ing up.  It  is  only  slightly  movable  under  the  skin, 
see  figure  3,  but  the  skin  is  freely  movable  over  it,  and 
"s  quite  hard. 

The  secretion   forms  so  slowly  that  the  patient  is 


10  DISEASES     OF     THE      EYE 

unaware  of  the  development  of  any  swelling  and  it  is 
never  noticed  until  it  reaches  the  size  of  a  small  pea, 
when  the  skin  begins  to  bulge  and  they  notice  there 
is  some  interference  with  fully  opening  the  lid,  then 
they  become  aware  of  its  presence. 

It  is  seldom  seen  in  children,  but  is  a  disease  chiefly 
confined  to  adults,  or  adolescents. 

The  treatment  is  surgical  and  should  be  done  early 
before  the  contents  of  the  cyst  have  undergone  any  de- 
generative changes  which  renders  it  liable  to  break- 
through the  inner  surface  of  the  lid.  The  operation 
is  done  under  local  anesthesia,  is  painless,  and  heal- 
ing usually  complete  in  a  few  days  without  any  deten- 
tion from  one's  vocation. 

ENTKOIMON,    KCTKOl'ION,    AND    TRICHIASIS. 

Other  lid  troubles  which  the  optometrist  should  be 
able  to  recognize  and  should  refer  to  an  oculist  for 
treatment  are,  entropion,  ectropion  and  trichiasis. 

Entropion  is  an  inversion  of  the  lid,  a  turning  in 
of  the  edge  of  the  lid  so  that  the  lashes  rub  on  the  eye- 
ball. This  is  usually  the  result  of  the  trachoma  (gran- 
ulated eye-lids)  and  is  due  to  the  formation  of  a  cica- 
trix (scar)  and  its  contraction;  the  old  granulations 
in  healing  leave  a  scar  which  contracts  as  all  scar  tis- 
sue does  and  causes  a  drawing  of  the  conjunctiva  with 
a  bending  of  the  tarsal  cartilage  and  the  pulling  of  the 
lid  in  toward  the  eye-ball.     See  figure  4. 

This  is  a  very  serious  condition  and  requires  surgi- 
cal interference  to  restore  the  edge  of  the  lid  to  its 
normal  position ;  nothing  can  be  done  to  repair  the 
damage  already  done  to  the  cornea  by  the  scratching, 
or  to  restore  the  delicate  and  velvety  conjunctiva 
which  has  been  replaced  with  the  hard  glazed  scar 
tissue. 


ANn    HOW     RECOGNIZED.  11 

This  condition  is  also  met  with  in  people  who  have 
had  the  granulations  treated  with  caustics,  such  as  sil- 
ver nitrate,  copper  sulphate,  etc.,  or  from  the  result 
of  burns  by  acids,  lime,  lye  or  other  caustic  agents,  it  is 
also  seen  in  ckl  people  who  have  flabby  lids  with  a 
spasmodic  contraction  of  the  orbicularis  muscle  which 
causes  an  inversion  of  the  lid. 

In  long  standing  cases  the  sclera  is  greatly  inflamed, 
a  beefy  red ;  there  is  profuse  lachrymation  and  the  cor- 
nea appears  hazy,  has  a  white  and  dead  look  due  to  the 
constant  scratching  of  the  lashes  or  hard  scar  tissue 
lining  the  lids,  or  both. 

This  condition  should  be  remedied  as  early  as  pos- 
sible so  as  to  save  what  vision  is  left,  before  a  dense 
white  scar  or  leucoma  forms  over  the  cornea.  The 
treatment  is  purely  surgical. 

Ectropion  is  just  the  reverse  of  the  above  and  is 
an  eversion  of  the  lid,  a  turning  out  of  the  edge  of  the 
lid,  so  that  the  conjunctiva  is  exposed.  The  sensitive 
lining  of  the  hd  becomes  glazed  and  shining.  See  fig- 
ure 5. 

There  are  various  causes  assigned  to  the  causation 
of  this  trouble,  among  which  are, — paresis  of  the  jtli 
nerve  allowing  the  lower  lid  to  droop  through  the 
paralysis  of  the  orbicularis  (paralytic  ectropion)  or  it 
may  follow  a  spasm  of  the  same  muscle  due  to  some 
local  irritation  (spasmodic  ectropion)  or  as  is  often 
the  case  it  occurs  in  old  people  as  the  result  of  atro- 
phy of  the  orbicularis  (senile  ectropion)  or  it  may 
occur  as  the  result  of  burns,  cuts  and  injuries  to  the 
lid  which  in  healing  leaves  a  scar  which  contracts  antl 
pulls  the  lid  away  from  the  eye-ball  (cicartricial  ec- 
tropion). 

The  treatment  is  as  before,  surgical;  and  should  be 
done  early,  for  obvious  reasons. 


DISKASF.S     or     THE      EYE 


I'iS.  IV- — Entrojiion  with  trichiasis.  The  edge  of  tlie  upi)er 
in  so  tliat  the  laslies  scratch  across  the  eye  ball,  giving  it  a  wliite  and 
ilead  appearance.  The  entire  conjunctiva  is  greatly  inflamed,  a  regu 
lar   network   of   vessels  are   seen   extending   over   the   sclera. 

Fig.    v.— Ectropion    of    the    lower,  liil.      Note    the    lurning    oul    of    llic 
lid,   exposing  the   sensitive   lining  to   the   air   and   dust. 


AND     HOW     RECOGNIZED.  13 

Accompanying  this  trouble  is  the  constant  overflow 
of  tears,  more  marked  of  course  upon  exposure  to  the 
wind  or  dust;  the  lower  lid  being  turned  away  from 
the  eye-ball,  the  tears  do  not  drain  into  the  tear  duct 
but  flow  out  over  the  cheek,  which  soon  causes  a 
roughness  of  the  skin  of  the  cheek  and  lid  and  re- 
sults in  an  "excoriation"  or  chapped  condition  of  the 
skin. 

This  overflow  of  tears  is  called  "epiphora"  and  is 
also  met  with  in  other  conditions,  particularly  that 
of  closure  of  any  part  of  the  tear  duct,  which  will  be 
considered  later  on. 

Trichiasis  is  a  term  applied  to  an  irregular  curving 
of  the  lashes  so  that  some  of  them  rub  on  the  ball,  this 
is  miscalled  "wild  hairs."  It  usually  accompanies  en- 
tropion but  may  occur  with  any  inversion  of  the  lid. 
The  treatment  of  this  troublesome  condition  depends 
largely  on  the  character  of  the  trouble  and  the  cause ; 
sometimes  where  there  are  only  a  few  lashes  causing 
the  trouble  the  offending  ones  are  removed  or  de- 
stroyed by  electrolysis  or  restored  to  their  normal 
position  by  surgical  interference. 

When  there  are  two  rows  of  lashes ;  the  ones  along 
the  inner  edge  of  the  lid  may  be  small  and  white  and 
grow  irregularly,  turning  in  against  the  sensitive  eye- 
ball, this  causes  an  inflammation  of  both  the  bulbar 
and  palpebral  conjunctiva,  with  an  increased  flow  of 
tears  and  this  condition  is  truly  that  of  "wild  hairs" 
or  as  it  is  called,  "distichiasis,"  and  the  small  and  al- 
most invisible  hairs  must  be  removed  or  destroyed  by 
the  electric  needle. 


14  DISEASES     OF     THE      EVE 

I  SECOND  SERIES. 

Part  1. — Exiernai.  Diseases  of  the  Eyehai.e 
AND  Ln)S. 

\vn  now  notice  the  eve  is  more  or  less  red. 

Your  next  query  to  answer  is — why? 

The  conjunctiva  is  sui)i)He(l  with  two  sets  of  blood 
vessels,  the  anterior  and  the  iwsterior,  which  is  well 
to  remember  on  account  of  their  diagnostic  value  in 
determining  the  character  of  the  inflammation. 

Scars  or  leucomrc  of  the  cornea  following  old  gran- 
ulated lids  are  often  accompanied  by  an  invasion  of 
the  cornea  bv  small  blood  vessels — pannus,  as  it  Is 
called. 

In  the  more  common  inflammations  of  the  eye,  it 
becomes  necessary  to  ascertain  whether  the  deeper 
structures  are  involved ;  to  determine  this,  we  notice 
whether  or  not  the  vessels  move  with  a  movement  of 
the  conjunctiva;  this  being  loosely  attached,  can  be 
readily  moved;  if  the  redness  moves  with  it.  .the  in- 
flammation is  one  involving  the  superficial  structures, 
while  if  the  redness  docs  not  move,  the  inflammation 
is  one  of  deeper  character  and  the  deep  vessels  are  in- 
volved;  both  conditions  frequently  exist  together. 

In  deep  seated  inflammatirns  the  greatest  zone  of 
redness  is  immediately  around  the  cornea-scleral  junc- 
tion, as  will  be  shown  in  iritis,  whereas  in  the  more 
superficial  inflammations  the  greatest  areas  of  red- 
ness are  at  the  "retro-tarsal  f  )lds." 

Now,  remember  that  the  vessels  which  you  see  so 
prominent  in  an  inflammed  eye  are  so  small  as  scarce- 
ly to  be  seen  in  a  healthy  eye. 

Pain  is  another  factor  which  must  be  considered^  in 
the  study  of  eye  inflammations,  and  we  can  divide 
these  diseases  into  two  general  classes;  in  the  first, 
(a)    the    eye    is    wholly   or   partly    inflamed    without 


AND     HOW     RFXOGNIZED.  15 

pain  or  discomfort;  in  the  second,  which  can  be  sub- 
divided, there  will  be  in  the  one  more  or  less  discom- 
fort without  actual  pain,  whereas  in  the  other  (b) 
class  the  eye  is  distinctly  discomfortable  but  very  lit- 


FijT.    \'I. — Everting  the   lower   I'd, 


16  DISEASES     OF     THE     EYE 

tie  or  no  pain,  in  the  other  (c)  class  the  eye  is  quite 
painful. 

The  first  class  (a)  is  seldom  seen  and  rarely  occur.; 
except  in  the  case  of  sub-conjunctival  hemorrhagic  in 
the  second  class  (b)  there  is  discomfort,  itching,  burn 
ing  and  smarting  with  lachrymation  and  photophobia 
and  more  or  less  of  a  discharge,  all  of  which  may  be 
present  in  a  single  case.  It  is  diseases  of  this  class  that 
we  consider  in  this  paper. 

The  posterior  conjunctival  vessels  are  prominent  in 
the  diseases  we  arc  going  to  consider  in  this  paper, 
they  are  the  ones  which  are  responsible  for  the  red- 
ness. They  become  bright  red  with  the  engorgement 
of  blood  and  move  with  the  conjunctiva. 

The  anterior  ciliary  vessels  supply  the  sclera,  iris 
and  ciliary  body  and  a  congestion  of  these  vessels 
gives  the  "zone  of  circumcorneal  congestion"  as  seen 
in  iritis,  cyclitis,  etc.,  and  docs  not  move  with  the  con- 
junctiva. 

Look  closely — is  there  any  "mucus"  or  any  secre- 
tion? If  so,  is  it  clear,  thin  and  semi-transparent  and 
"stringy"  or  is  it  thick  and  of  a  yellowish  color?  Or 
is  there  an  absence  of  any  mucus  or  secretion,  but 
just  an  excessive  flow  of  tears? 

Foreign  bodies  in  the  eye — cinders,  a  lash  or  any 
of  the  more  common  forms  of  foreign  bodies  cause 
the  stringy  form  of  mucus,  whereas  true  inflamiua- 
tory  conditions  brought  about  by  micro-organisms 
gives  rise  to  the  thick  and  creamy  secretion,"  or,  as  it 
is  more  correctly  called,  a  "muco-purulent  discharge." 

In  cases  where  the  foreign  body  has  been  in  the 
eye  only  a  short  time  and  in  iritis  (and  some  other 
diseases),   there  is  only  the   "profuse   lachrymation." 

As  foreign  bodies  are  of  such  common  occurrence 
we  will  first  consider  that  point. 

First  look  for  the  offending  particle  on  the  eyebill. 


AND     HOW     RECOGNIZED. 


have  the  patient  look  up,  down,  toward  the  nose  or 
toward  the  temple-^if  it  is  not  on  the  cornea  it  can 


Fig  VII  — First  act  of  everting  upper  lid,  the  margin  of  the  lid  is 
grasped  between  the  thumb  and  forefinger  and  ilulled  down  and  away 
from  the  eyeball. 


18  DISEASES     OF      THE      EYE 

be  wiped  off  with  a  tuft  of  cotton  on  a  tooth  pick,  but 
if  it  is  on  the  cornea  it  will  be  better  to  use  a  local 
anaesthetic,  such  as  cocaine,  alypin,  beta-eucaine,  etc  , 
and  you  will  refer  your  patient  to  some  friend  who  is 
an  oculist. 

And  right  here  let  nic  say — don't  send  your  patient 
but  go  with  him,  introduce  him  to  the  oculist,  and  all 
concerned  will  be  better  satisfied.  The  patient  will 
feel  that  you  are  taking  more  than  ordinary  interest 
in  him  and  will  be  far  better  satisfied ;  will  pay  the 
oculist's  bill  with  better  grace,  and  for  some  reason 
or  other  seems  to  feel  that  you  have  his  welfare  at 
heart,  and  that  you  have  confidence  in  the  man  to 
whom  you  are  taking  him.  and  it  at  once  inspires  his 
confidence   in   the   oculist. 

Also  reassure  him  that  he  will  not  be  "robbed," 
and  then  take  him  to  a  man  that  you  know,  and  know 
to  be  one  who  is  not  engaged  in  the  practice  of  medi- 
cine solely  for  the  money  that's  in  it — just  look  around 
and  you  will  find  such  a  man,  and  take  him  to  a  man 
who  is  not  so  extremely  pressed  for  time  but  what 
he  can  give  the  patient  the  attention  due  him,  for 
careful  eye  work  takes  time ;  you  can't  hurry,  and  the 
busy  man  must  hurry  unless  he  has  an  assistant  or 
two. 

Remember  this  if  you  want  a  "square  deal"  for  the 
patient  and  yourself. 

Again,  many  people  have  the  idea,  born  either  of 
hearsay  or  experience,  that  they  will  be  "stuck."  Now, 
the  fee  for  removing  a  foreign  body  varies  from  nothing 
to  ten  dollars,  and  usually  among  some  of  the  busier 
men  the  customary  charge  is  $5.  I  have  done  it  more 
times  for  nothing  than  I  have  for  the  five  and  find  it 
pays. 

The  onlv  danger  from  a  foreign  h(^dv  is  the  like- 
lihood of  the  formation  of  a  corneal  ulcer,  and  to  quote 


AND     HOW     RECOGNIZEn. 


from  a  recent  article  of  luiiie  in  one  of  tlic  medical 
journals : 

"A  small  ami  shallow  nicer  is  (|nite  common  after 


Fig.    VIII.— Iiisprctin.u    the    11, .pn-    li,l    aft( 


20  DISEASKS     OF     THE      EVE 

the  lodgement  of  a  foreign  body  in  the  eye,  especially 
in  aged  or  debilitated  persons;  but  in  the  young  and 
robust,  may  cause  little  or  no  trouble,  and  may  never 
be  discovered — after  a  few  days  heal  without  any 
treatment  whatsoever,  the  patient  never  having  been 
aware  of  its  presence. 

"The  cause  of  so  frequent  ulceration  of  the  cornea 
depends  upon  various  influences,  yct.thc  most  generally 
accepted  etiological  factor,  i)erhaps,  is  the  established 
fact  of  the  frequent  presence  of  bacteria  in  the  con- 
junctiva which  find  a  ready  field  for  growth  in  an 
abraded  cornea." 

So  that  it  is  a  safe  procedure  to  have  the  patient  use 
a  mild,  soothing  and  antisejitic  collyrium  so  as  to 
eliminate  the  possibility  of  an  ulcer  forming;  this  is 
especially  advisable  if  the  body  has  lodged  directly  on 
the  cornea  or  has  been  in  the  eye  for  a  day  or  so. 

To  find  a  foreign  body  it  is  usually  necessary  to 
"turn  the  lids."  the  upper  one  in  particular. 

First  look  at  the  lower  lid — to  do  this,  place  the  tip 
of  the  finger  near  the  margin  of  the  lid  and  draw  it 
down,  tb.en  push  the  finger  backward  (you  can  feel  the 
lower  rim  of  the  socket  as  your  finger  goes  over  it)  ; 
at  the  same  time  direct  your  patient  to  look  up,  "way 
up."  at  the  ceiling  just  over  their  head. 

To  get  a  look  at  the  inner  surface  of  the  upi^cr  lid 
is  more  difficult,  but  after  practicing  it  a  few  times  on 
yourself  you  will  become  quite  adept. 

First  direct  the  patient  to  look  down  and  to  keep 
look{ns[  doivn  during  the  entire  proceedino;  (with  the 
head  tilted  back  about  the  way  in  Fig.  VII.;  the  knees  ■ 
off"er  about  the  best  place  to  direct  them  to  look),  now 
take  your  place  behind  and  a  little  to  the  side  and 
catch  the  edge  of  the  lid  (not  the  lashes)  between 
your  thumb  and  forefinger  and  pull  it  away  from  the 
evcball  as  shown  in  Fig.  VIT. 


AND     HOW     RECOGNIZED.  21 

At  the  same  time  you  do  this,  some  small  blunt  in- 
strument— a  pencil,  match  or  your  finger  tip,  is  placed 
at  the  upper  edge  of  the  tarsal  cartilage  and  pressed 
downward ;  at  the  same  instant  the  lid  is  quickly  turned 
over  it. 

Now,  by  directing  your  patient  to  continue  looking 
down,  you  can,  by  placing  your  finger  on  the  margin 
of  the  everted  lid,  hold  it  in  this  position  and  exam- 
ine it  thoroughly. 


SECOND   SERIES    (Continued). 

Part  fl. — External  Diseases  oe  the  Eyeball 
AND  Lids. 

In  looking  for  glass  on  the  ball  or  lid  it  is  usually 
necessary  to  use  "oblique  illumination,"  as  in  looking 
for  cataract,  which  will  be  described  later  on.  This 
will  show  the  glass  very  plainly,  the  use  of  a  strong 
magnifying  glass  will  also  aid  in  locating  the  piece  of 
glass  you  are  searching  for. 

The  eye  appears  inflamed  or  red ;  this  may  be 
due  to  an  infectious  conjunctivitis,  foreign  body,  ulcer, 
iritis,  irritation,  or  eyestrain. 

We  will  first  consider  simple  inflammation,  such  as 
is  seen  in  the  case  of  a  foreign  body,  irritation  and 
eyestrain. 

This  is  called  "hyperemia  of  the  conjunctiva"  and  is 
chiefly  confined  to  the  lids  and  outermost  portions  of 
the  sclera.  These  appear  redder  than  normal  and  the 
blood  vessels  of  the  l)ulbar  conjunctiva ;  those  on  the 
eyeball  are  large  and  dilated  with  blood. 

There  is  no  discharge,  but  the  patient  may  com- 
plain of  itching,  burning  and  smarting  with  a  feeling 
of  roughness  of  the  lids,  which  may  upon  arising  in 
the  morning  feel  "thick  and  gummy." 


DTSF.ASF.S      OF      TTTF      RVE 


I'ig.    IX. — Sinii>le    liyi>cr.Tniin    of    tlie    eye     (simple    inflaiuniatioii.) 

Fig.  X. — Catarrh  conjunctivitis  (cxaRgcrateiH.  Notice  the  glueing 
together  of  the  lashes  in  clumps  and  the  marked  inHammation  of 
ilie    conjunctiva. 


AND     HOW     RECOGNIZED.  23 

This  is  commo;i  in  eyestrain,  either  from  uncor- 
rected refractive  errors  or  from  any  un(kie  effort, 
such  as  attempting  to  see  through  a  cataractous  lens 
or  corneal  opacity. 

It  is  also  found  in  smokers,  engine  drivers,  persons 
exposed  to  wind,  irritating  dusts  and  gases  and  in  a 
"cold." 

Notice  Fig.  IX ;  fix  this  picture  in  your  mind  so 
as  to  compare  it  with  the  congestion  of  iritis. 

Next  we  have  inflammations  due  to  infection,  which 
while  similar  to  the  above,  are  more  severe  and  of  a 
more  aggravated  form  with  the  "muco-purulent  dis- 
charge." 

This  begins  with  a  sensation  of  smarting  and  burn- 
ing, with  a  feeling  of  sand  in  the  eye ;  the  lids  usually 
stick  together  in  the  mornings. 

The  conjunctiva  of  the  lids  is  red  and  swollen,  there 
is  generally  more  or  less  photophobia  or  undue  sen- 
sitiveness to  light  and  profuse  lachrymation.  Notice 
Fig.  X ;  this  is  similar  to  Fig.  IX,  except  the  eye  is 
more  inflamed  and  the  lashes  are  stuck  together  in 
clumps,  much  as  they  were  in  Fig.  I  of  the  last  series 
illustrating  blepharitis  marginalis. 

The  bulbar  conjunctiva  is  markedly  congested,  the 
vessels  seemingly  gorged  with  blood  almost  to  the 
bursting  point,  with  more  or  less  "puffiness'*  of  the 
conjunctiva;  this  is  more  marked  at  the  junction  of 
the  lid  and  eyeball,  in  the  "retro-tarsal  folds,"  as 
it  is  called. 

This  disease  may  accompany  "grippe"  or  even  a 
bad  "cold."  One  form  of  this  disease  is  highly  con- 
tagious and  of  a  little  more  severe  type  and  is  known 
as  "acute  contagious  conjunctivitis,"  or  in  popular 
terms,  "pink  eye,"  and  occurs  quite  often  as  an  epi- 
demic, usually  in  the  months  of  spring  and  fall. 

The  term  pink  eye  was  given  it  on  account  of  the 


24  DISEASES     OF     THE      EVE 

marked  congestion  ;  "red  eye"  would  perhaps  be  more 
applicable. 

With  this  latter  trouble  there  is  often  some  eleva- 
tion of  the  bodily  temperature. 

Where  there  is  much  discharge  or  great  inflamma- 
tion, the  pus  should  be  examined  microscopically  to 


Fig.  XI. — Pterygium  growing  from  tlie  inner  cantluis  of  the  right 
eye;    it    lias   already    started    to   grow    over    the    cornea. 

Fig.  XII. — Leucoma  or  opacity  of  the  cornea,  drayish  colored  spot 
on  the  upper  portion  of  tlie  cornea,  disfigures  the  eye,  and  in  this 
case  interferes  with  vision  when  looking  up,  and  some  impairment  of 
vision  all  the  time,  due  to  haziness  of  the  cornea,  which  does  not 
show   in   the   picture. 


AND     now     RECOGNIZED.  25 

cliiniiiatc  the  uncertainly  uf  it  being  gonurrhcal.  Gon- 
orrheal ophthalmia  is  a  decidedly  dangerous  atfection 
and  the  large  majority  lose  their  eyes. 

Another  condition  commonly  met  with  and  one  in 
which  there  is  more  or  less  redness  of  the  eyeball,  is 
pterygium   (terig-ium.) 

This  is  a  growth  on  the  eyeball  starting  usually  at 
one  corner  (canthus),  and  as  a  rule  the  inner  canthus. 
They  grow  very  slowly  as  a  rule,  and  give  little  or 
no  trouble  except  in  cases  where  a  person's  vocation 
keeps  him  out  of  doors  in  the  wind  and  dust;  in  such 
cases  they  prove  very  irritating  and  grow  quite  rap- 
idly. 

They  may  stand  up  from  the  eyeball,  as  in  the 
"fatty"  type  and  offer  a  catch-all  for  any  particles  of 
dust  that  are  floating  around,  or  they  may  lie  per- 
fectly flat  and  never  be  noticed  unless  the  eye  becomes 
inflamed,  when  they  will  stick  up  and  become  notice- 
able. 

This  is  a  triangular  growth,  with  its  base  spread- 
ing out  at  the  canthus  and  the  apex  extending  up  to- 
wards the  cornea. 

Its  etiology  is  somewhat  obscure ;  it  is  common  in 
people  exposed  to  wind  and  dust :  sailors,  engi- 
neers, farmers,  motormen  and  others  whose  calling 
compels  them  to  be  out  in  all  sorts  of  weather  are 
subject  to  this  trouble. 

It  not  only  greatly  disfigures  an  eye,  but  renders  it 
more  susceptible  to  inflammation  and  infection,  and 
it  is  unsafe  to  operate  on  an  eye  with  a  pterygium, 
especially  if  the  operation  is  one  on  the  iris  or  lens. 

A  pterygium  should  be  removed  before  it  grows 
over  the  cornea.  Just  as  soon  as  it  reaches  the  limbus 
it  should  be  removed,  sooner  if  possible,  as  it  destroys 
the  vision  if  it  grows  over  the  cornea.  The  treatment 
is  purely  surgical.     The  operation  is  done  under  local 


26  liISEASES     OF      THE      KYE 

anesthesia,  is  painless  and  healing  is  usually  complete 
within  a  few  clays,  without  any  detention  from  one's 
business. 

Another  trouble  which  may  be  mistaken  for  ptery- 
gium by  the  uninformed  is  a  leucoma  or  scar  of  the 
cornea. 

This  appears  as  a  white  or  grayish  scum  over  the 
same  portion  of  the  cornea,  usually  in  the  upper  part 
and  is  generally  due  to  an  old  case  of  granulated  lids 
or  the  scratching  of  the  scar  tissue,  which  follows  the 
healing  of  the  granulations. 

Burns  or  injuries  also  cause  this  form  of  opacity, 
or  it  may  follow  inflammation  of  the  cornea,  ulcers 
or  the  use  of  strong  and  irritating  medicines,  and  al- 
most  follows  gonorrlical  ophthalmia  of  the  new-born. 

It  appears  as  a  dull  spot,  the  edges  of  which  are 
less  opaque  than  at  the  center,  the  cornea  surrounding 
it  is  usually  infiltrated  and  hazy.  The  opacity  itself 
varies  in  size,  location  and  shape. 

Where  the  opacity  is  dense  or  greatly  disfigures  it 
may  be  tattooed;  this  is  done  with  various  colored 
chemicals  and  is  very  hard  to  detect  if  properly  done; 
and  iris  is  painted,  so  to  speak,  over  the  cornea;  this 
has  to  be  done  about  every  six  months  to  make  it 
look  natural. 

Figure  XII  shows  a  leucoma  on  the  upper  portion 
of  the  cornea  due  to  old  granular  lids ;  this  is  the 
most  common  site  of  its  formation,  and  trachoma  is 
the  most  frequent  cause. 


AND     now     RECOGNIZED.  27 

PART  III. 

Dtsi'.asks  of  the  Eve. 

Now  that  you  have  learned  to  "evert  the  lids"  you 
will  be  able  to  diagnose  some  of  the  more  common  lid 
diseases  and  the  two  we  will  consider  in  this  paper 
will  be  follicular  conjunctivitis  and  trachoma  or  "gran- 
ulated lids." 

Follicular  conjunctivitis  is  a  form  of  catarrhal  con- 
junctivitis with  the  over  development  of  the  "lymph 
follicles." 

On  everting  the  lids,  particularly  the  lozver  one,  you 
will  notice  numerous  small,  pale,  round  semi-trans- 
lucent spots  or  granules,  which  are  often  arranged  in 
rows  extending  across  the  lid  parallel  to  the  margin. 
They  are  more  numerous  at  the  "fornix"  or  junction 
of  the  palpebral  and  bulbar  conjunctiva. 

In  this  disease  there  is  a  sticky  mucus  secretion 
which  causes  a  sticking  together  of  the  lids  in  the 
morning.  The  conjunctiva  of  the  lids  looks  "puffy" 
and  is  quite  inflamed  but  the  bulbar  conjunctiva  is 
not  so  much  affected,  it  is  usually  slightly  inflamed  but 
not  markedly  congested  as  in  some  of  the  other  dis- 
eases we  have  studied. 

There  is  photophobia  and  lachrymation,  with  the 
itchy  feeling  of  sand  in  the  eyes,  causing  the  patient 
to  unconsciously  rub  them.  This  disease  is  more  com- 
mon in  young  people,  particularly  among  those  whose 
surroundings  are  unhygienic,  or  where  many  are 
crowded  together,  common  among  the  tenement  classes 
and  in  schools. 

As  to  its  being  contagious,  that  question  has  caused 
more  or  less  discussion  and  disagreement  among  the 


28  DISEASES     OF     THE      EYE 

authorities.  There  is,  however,  plausible  reason  to  be- 
heve  that  it  is  slightly  contagious,  since  several  mem- 
bers of  a  family  or  a  number  of  pupils  of  a  sing'e 
school-room  will  have  the  disease  at  the  same  time. 

It  is  not  a  disease  of  serious  consequences,  but  is 
quite  aggravating  and  persistent. 

It  differs  very  much  from  trachoma  and  should  not 


Fig.  XIII.  Follicular  conjunctivitis,  bmall  round  elevations  more 
numerous  at  the  fornix.  Eyeball  only  slightly  inflametl;  much  secre- 
tion, which  causes  the  lashes  to  become  glued  together  in  clumps. 
Tliis  gluing  together  of  the  lashes  is  not  often  seen,  as\  the  patient 
usually  washes  his  eye  before  appearing  at  the  ofhce  and  the  lashes 
may   appear   straight   and    normal. 

he  mistaken   for  it;  such  a  mistake  rarely  occurs  in 
the  diagnosis  by  the  well  informed. 

Remember  that  this  disease  docs  not  affect  the  deep- 
er structures  of  the  lid  but  is  confined  to  the  conjunc- 
tiva proper.  The  treatment  consists  in  improving  the 
patient's  unsanitary  surroundings  or  in  removing  him 


AND     HOW     RECOCINIZED. 


from  them ;  correcting  refractive  errors ;  eye-rest ;  and 
looking  after  the  general  health,  etc. 

Trachoma  or  granulated  lids  is  a  dirt  disease,  a  dis- 
ease of  the  poor  tenement  classes,  it  is  also  highly  con- 
tagious, and  because  it  is  so  easily  contracted  it  is  now 
seen  among  nearly  all  classes  of  society.  It  is  gener- 
ally followed  by  a  long  train  of  serious  and  compli- 
cated scquelx  as  we  have  already  seen. 


Fig.  XIV.  Early  stage  of  trachoma,  seldom  seen.  Lashes  may 
appear  glued  together,  especially  if  the  cases  are  among  poor  tliildren 
who  have  not  been  washed  before  the  visit  to  the  office.  Eyeball 
slightly  inflamed,  with  a  few  large,  prominent  granules  standing  out 
from  the   conjunctiva. 

The  acute  stage  of  the  disease  is  seldom  seen,  unless 
it  is  discovered  accidentally  in  testing  the  eyes,  but 
when  the  patients  come  to  us  complaining  of  the  trou- 
ble it  has,  as  a  rule,  reached  a  more  or  less  chronic 
stage. 

The  symptoms  of  the  acute  stage  much  resemble 
those  of  the  other  diseases,  lachrymation,  photophobia 
with  a  mucus  or  muco-purulent  discharge, — occasion- 


30  DISF.ASKS      OF      THK      EVE 

ally  ulcers  of  the  cornea, — with  great  swelling  and  in- 
flammation of  the  palpebral  conjunctiva  with  some 
congestion  and  pufifiness  of  the  bulbar  conjunctiva,  and 
the  granulations  are  usually  hidden  by  the  swollen 
conjunctiva  and  may  be  overlooked. 

We  generally  see  the  diseases  after  the  acute  symp- 
toms have  partially  subsided  and  the  disease  has  pro- 
gressed to  the  chronic  stage  and  the  patient  may  com 
plain  of  nothing  more  than  the  feeling  of  sand  in  the 
eye,  which  is  aggravated  by  wind  and  dust. 

On  everting  the  lids, — [jarticularly  the  upper  one. — 
we  see  a  number  of  irregularly  shaped  granulations, 
grayish  in  color,  resembling  grains  of  sago  which 
seem  to  project  from  the  conjunctiva. 

They  are  more  abundant  at  the  retro-tarsal  folds 
and  are  imbedded  in  the  conjunctiva  and  involve  the 
deeper  structures,  thus  differing  from  the  preceding 
disease. 

If  seen  late  in  the  development  of  this  disease  you 
will  notice  that  some  of  the  granulations  have  been  re- 
placed by  a  small  shining  scar. 

Later  the  scars  become  so  numerous  that  they  seem 
to  have  coalesced  and  much  of  the  conjunctiva  has 
been  replaced  by  this  cicatricial  (scar)  t'ssue  which 
causes  entropion,  trichiasis  and  pannus  with  more  or 
less  opacity  of  the  cornea. 

The  treatment  depends  on  the  stage  of  the  disease, 
and  consists  of  expressing  the  contents  of  the  granu- 
lations by  means  of  various  instruments :  the  opera- 
tion is  quite  painful  unless  done  under  a  general  an- 
esthetic, such  as  ether  or  chloroform. 

The  use  of  the  various  caustics  in  this  disease  is 
not  advisable,  because  it  is  impossible  to  control  their 
action  or  limit  the  effects.  T  prefer  the  slower  and 
more  conservative  methods:  the  ft^-m  of  treatment  I 


AXn     TTOW     RKrOONTZF.I).  31 

have  usrd  witli  niucli  success  is  that  of  ['rincc.  wliich 
consists  of  instillations  of  a  solution  of  pure  copper 


l"ig.  W.  Later  stage  of  trachoma.  Granulations  have  begun  to 
heal,  leaving  scars,  which  has  caused  a  scum  to  form  over  the  upper 
portion    of   the    cornea.      Eyeball   markedly    congested. 


I'ig.  XVI.  Last  stages  of  trachoma.  Almost  the  entire  upper  lid 
is  a  mass  of  scars,  which  lias  caused  much  scratching  of  the  cornea 
and  has  produced  a  dense  leucoma  in  which  there  appears  small  blood 
vessels  (Pannus).  The  eyeball  is  in  a  state  of  chronic  congestion.  The 
disease  has  progressed  too  far  to  ever  do  much  with  it,  so  far  as 
restoring    the    vision. 


32  niSKASES     OF     THE      EYE 

sulphate  in  ylyccrinc;  this  is  done  every  day  for  a  pe- 
riod of  considearble  time,  the  amount  of  copper  be- 
ing gra(hially  increased  each  week.  With  this  treat- 
ment instillations  of  some  of  the  mild  astringent  and 
antiseptic  collyria  are  made  into  the  conjunctival  sac. 
The  use  of  the  copper  sulphate  stick  is  dangerous 
and  the  far  reaching  after-efifects  may  be  as  bad  as 
the  disease  itself. 

lU.ClCRS  OK  Till-;  COKN'l-:.\. 

Owing  to  its  metabolism  the  cornea  is  prone  to  ul- 
cerate after  any  abrasion  of  its  surface.  The  presence 
of  various  bacteria  on  the  conjunctiva  has  been  dem- 
onstrated; these  micro-organisms  readily  find  a  fertile 
field  for  growth  on  an  abraded  cornea. 

Ulcers  of  the  cornea  are  of  such  frecjuent  occur- 
rence, and  the  accompanying  intense  pain  and  pro- 
longed suffering,  with  the  serious  complications  and 
untoward  eiifects  which  follow,  that  it  behooves  every 
optician  to  be  constantly  on  the  lookout  for  this  disease 
and  make  his  diagnosis  early,  so  that  the  patient  may 
have  prompt  treatment. 

We  conunonly  see  ulcers  after  tb.e  lodgement  of  a 
foreign  body  in  the  eye:  also  after  the  use  of  caustics 
in  the  treatment  of  trachoma. 

The  cornea  being  devoid  of  blood  vessels,  its  nu- 
trition is  less  well  assured  and  its  struggle  against  in- 
fection less  efificient. 

The  first  thing  we  notice  in  the  early  development  of 
an  ulcer  is  the  localized  hazy  spot  on  the  cornea,  later 
the  central  portion  of  this  spot  breaks  down  and  ul- 
cerates, the  edges  being  rough,  ragged  and  slightly  un- 
dermined. 

Oftent'mcs  the  entire  cornea  may  lose  its  glistening 
appearance     and     become  hazy  and  look  "steamed." 


AND     now     RECOGNIZED. 


There  is  the  most  intense  photophobia,  lachrymation 
is  profuse  and  the  pain  is  severe. 

If  the  ulcer  is  near  the  periphery  of  the  cornea, 
there  will  be  seen  a  small  leash  of  blood  vessels  run- 
ning up  to  the  limbus  and  the  whole  conjunctiva  will 
be  congested. 

An  ulcer  of  the  cornea  is  so  readily  detected  that 
anv  more  on  the  diagnosis  would  be  superfluous ;  but, 


FiR.  X\  II.  Ulcer  of  the  cornea.  Notice  the  small  leash  of  blood 
vessels  extending  up  to  the  cornea.  The  bulbar  conjunctiva  is  mark- 
edly inflamed  and  the  cornea  surrounding  the  ulcer  is  less  transparent; 
has  a  "steamed''   appearance. 

where  any  doubt  exists,  it  may  be  stained  with  a  drop 
or  two  of  a  2  per  cent  solution  of  potassium  fluori- 
cide.  This  stains  the  abraded  surface  and  the  edge  of 
the  ulcer  a  yellowish-green  and  the  extent  of  the  ul- 
cer can  be  readily  mapped  out. 

This  disease  causes  much  pain  of  more  or  less  se- 
verity, the  pain  radiating  over  the  brow  and  temple, 


DISEASES     OF     THE      EVE 


worse  cat  night.  Profuse  lachryniatioii  and  photopho- 
bia are  accompanying  disagreeable  symptoms  and  are 
quite  marked. 

There  is  usually  more  or  less  blepharospasm  and 
the  patient  has  difficulty  in  opening  the  lids,  especially 


Fig.  XVIII.  Staphyloma  of  the  eye.  This  is  the  result  of  a 
weakeninp  of  the  cornea  due  to  ulcers.  The  intra-ocular  pressure  is 
so  great  that  the  weakened  cornea  gives  way  before  it. 

in  a  bright  light.  Ulcers  always  leave  a  scar  with 
more  or  less  opacity,  depending  on  the  amount  of  tis- 
sue destroyed. 


AND     now     RECOGNIZED.  35 

Small  shallow  ulcers  heal  without  any  apparent  or 
appreciable  opacify,  simply  causing  a  little  irregular 
astigmatism. 

Deep  ulcers  are  serious.  Perforation  with  loss  of 
the  acqucous,  prolapse  of  the  iris  with  adhesions  are 
the  frequent  complications. 

There  are  various  forms  of  ulcers,  a  discussion  of 
which  would  render  this  too  lengthy;  suffice  it  to  say 
that  any  form  of  ulcer  should  have  prompt  and  ener- 
getic treatment. 

The  treatment  depends  upon  the  severity  of  the 
case,  hot,  moist  applications,  afford  a  grateful  relief. 
Antiseptic  lotions  and  atropine  are  the  usual  methods 
of  treating  this  disease. 

Occasionally  it  becomes  necessary  to  puncture  the 
cornea  to  prevent  a  staphyloma  and  to  have  the  per- 
foration where  it  will  interfere  the  least  with  vision. 

The  cornea  may  become  so  weak  that  the  intra-ocu- 
lar  pressure  causes  it  to  bulge,  and  the  puncture  is 
made  to  prevent  this. 

We  now  come  to  inflammation?  of  the  cornea,  or 
keratitis,  as  it  is  called.  The  first  form  of  this 
disease  we  will  consider  will  be  interstitial  keratitis. 

This  disease  may  be  due  to  hereditary  trouble  or 
may  be  acquired.  It  is  usually  due  to  inherited 
taint,  and  is  seen  quite  often  in  young  adults  and 
children ;  it  may,  however,  be  found  in  older  people 
as  the  result  of  acquired  constitutional  disease. 

There  are  cases  of  this  form  of  disease  in  which 
no  constitutional  taint  is  manifested;  it  is  claimed 
by  some  that  it  may  be  of  tubercular  origin. 

It  occurs  more  frequently  in  females  and  usually 
is  seen  between  the  fifth  and  twentieth  year,  rarely 
after  the  thirtieth. 

It  may  occur  without  any  supposed  cause,  or,  as 


36  IiISF.ASKS     OF     THE      EYK 

is  niurc  often  ihc  case,  it  will  appear  after  or  during 
an  attack  of  rheumatism  or  somft  acute  febrile  dis- 
ease, or  even  abuse  of  the  eyes  will  be  sufficient  to 
bring  on  an  attack. 

Usually  one  eye  is  affected  at  a  time,  but  both 
sooner  or  later  suffer  from  the  disease. 

In  hereditary  cases  there  will  often  be  found  the 
so-called  "Hutchinson  teeth,"  as  seen  in  Fig.  XIX. 

This  disease  aft'ects  the  middle  and  posterior  lay- 
ers of  the  cornea  and  starts  with  photophobia,  lacli- 


I'ig.    XIX. — Hutchinson    teeth.      Pegged    and    notched    variety. 

rymation,  blurring  of  the  vision  and  "pericorneal 
injection."  The  cornea  becomes  hazy  by  a  faint 
opacity  starting  near  the  limbus  and  gradually  ex- 
tending over  the  entire  surface,  forming  a  more  or 
less  dense,  smooth  opacity  which  renders  the  iris  in- 
visible; later  there  will  be  seen  minute  blood  ves- 
sels running  into  the  deep  layers  of  the  cornea.  As 
a  rule  the  iris  is  affected,  and  as  a  result  of  this 
iritis  synechia  may  form,  the  iris  adhering  either  to 


AND     now     RECOGNIZED. 


Fig.  XX. — Interstitial  Keratitis.  Entire  cornea  white  and  hazy, 
except  for  a  small  portion  at  the  lower  part.  Notice  the  ring  of  minute 
blood  vessels  surrounding  the  cornea — "peri-corneal  injection.  A  fev 
capillaries  are  seen  making  their  way  into  the  cornea  itself.  Eye  greatlv 
inflamed.      Cornea    so   hazy   that    the    pupil    is   difficult   to   see. 


Fig.    XXI.— Punctate    Keratitis.      Small    white    deposits   on    the    pos 
terior   surface  of  the   cornea. 


38  DTSFASKS     OF     THE      EYE 

the  lens  beliind  (posterior  synechia)  or  to  the  cornea 
in  front  (anterior  synechia). 

The  treatment  should  be  energetic  and  persistent 
and  consists  of  general  systemic  treatment,  with 
eye  treatment  depending  on  the  symptoms  and  se- 
verity of  the  disease. 

Fig.  XX.  shows  a  well  developed  case  of  this 
disease. 

Next  we  have  a  condition  which  often  accompanies 
inHanimations  of  the  uveal  tract,  i.  e.,  iris,  choroid  and 
ciliary  body. 

This  disease  is  characterized  by  deposits  on  the  pos- 
terior surface  of  the  cornea,  and  because  of  the  ap- 
pearance these  dots  give  the  cornea  the  name  punctate 
keratitis  has  been  given  to  the  condition.  It  is,  how- 
ever, not  a  disease  of  the  cornea,  but  only  a  symptom 
of  a  disease  of  the  deeper  structures;  and  where  this 
symptom  is  shown  the  examination  should  go  deeper 
and  search  for  trouble  of  an  inflammatory  character  of 
some  portion  of  the  uveal  tract. 

As  this  is  only  a  symptom,  we  do  not  treat  this,  but 
treat  the  disease  which  causes  this  symptom. 

There  is  a  disease  of  the  cornea  which  somewhat 
resembles  this  disease,  except  that  the  dots  are  situ- 
ated on  the  anterior  surface  of  the  cornea  and  appear 
as  small  grayish  elevations  scattered  irregularly  over 
the  cornea ;  this  is  usually  caused  by  acute  catarrhal 
conjunctivitis,  and  is  not  in  itself  a  dise3.se  of  any 
serious  consequences;  hot  applications,  together  with 
some  mild  antiseptic  collyrium,  is  all  that  is  required. 

There  are  other  forms  of  keratitis,  but  they  are 
of  comparatively  rare  occurrence,  and  we  will  not  con- 
sider them  in  this  brief  paper. 

Now  it  generally  happens  that  where  any  inflamma- 
tion has  involved  the  cornea,  be  it  an  ulcer  or  injury, 


AND     HOW     RECOGNIZED.  39 

or  a  true  keratitis,  there  is  always  a  scar  with  more  or 
less  opacity,  depending  upon  the  amount  of  tissue  de- 
stroyed. There  are  various  names  given  to  these 
opacities  depending  upon  the  density  of  the  opacity. 

An  opacity  can  be  readily  distinguished  even  at  a 
glance.  It  appears  to  be  a  scum  or  veil  over  the  cor- 
nea, with  or  without  any  inflammation  of  the  con- 
junctiva. 

Occasionally  a  person  will  complain  of  poor  vision 
and  the  eye  will  look  apparently  normal,  but  with 
oblique  illumination  you  will  notice  a  very  thin  and 
delicate  veil  over  the  cornea  or  some  portion  of  it. 


Fig.  XXII.- — Method  of  oblique  illumination  for  locating  opacities 
of  the  cornea,  irregularities  and  foreign  bodies.  Also  used  in  the 
diagnosis  of  cataract. 

Fig.  XXII.  shows  the  method  of  oblique  illumina- 
tion in  examining  the  cornea ;  this  same  method  is  also 
employed  in  examining  the  lens  for  the  detection  of 
cataract. 


40  DISKASKS     ( )1-      TllK      KVK 

Opacities  of  the  cornea  are  slow  in  yielding  to  treat- 
ment, but  if  the  opacity  is  not  of  too  great  a  density 
much  can  be  done  toward  improving  the  patient's  ap- 
pearance, although  clearing  up  the  cornea  will  in  many 
cases  not  add  greatly  to  the  vision. 

There  are  various  drugs  employed  for  this  purpose; 
I  have  found  thiosinamine  with  vibratory  massage  to 
act  the  most  quickly.  Where  the  density  of  the  opacity 
is  so  great  as  to  involve  the  deeper  layers  there  is  not 
much  to  be  done  except  to  tattoo  the  cornea.     This  re- 


Fig.  XXIII. — Pericorneal  injection.  A  congestion  from  the  an- 
terior ciliary  vessels  and  found  only  in  diseases  of  the  iris  and  ciliary 
body   and    involvements   of   the    cornea. 

quires  much  skill,  as  the  iris  must  be  matched  in  color 
and  markings  and  a  good  pupil  be  made.  The  tat- 
tooing wears  oflf  in  a  short  time,  so  that  it  has  to  be 
done  about  twice  a  year. 

We  have  studied  all  of  the  more  common  diseases 


now     RKCOCNiZKt). 


of  the  external  structures  of  the  eye,  and  now  pas:i 
to  diseases  affecting  those  structures  inside  the  eye. 

The  first  and  most  common  we  will  consider  will 
be  iritis,  or  inflammation  of  the  iris. 

There  are  various  causes  assigned  to  the  causation 
of  this  painful  inflammatory  disease,  but  the  most  com- 
mon is  the  same  constitutional  taint  we  saw  in  inter- 
sitial  keratitis. 

This  causes  about  sixty  per  cent.,  and  rheumatism 
causes  about  twenty  per  cent.,  the  remainder  is  divided 
up  among  eyestrain,  gout,  diabetes  and  other  systemic 
diseases. 


Fig.  XXIV. — Irregular  dilatation  of  the  pupil  after  the  use  of 
atropine.  Due  to  synechia  or  adhesions  of  the  iris  to  the  lens  as  the 
result  of  inflammatory  conditions  of  the  iris. 

This  disease  is  quite  painful  and  begins  with  pain 
in  the  eye  and  radiating  over  the  brow  and  temple  and 
over  the  side  of  the  nose.  The  eyeball  is  greatly  in- 
flamed, the  deep  vessels  being  involved,  giving  the  eye 


42  DISEASES     OF     THE      EVE 

the  appearance  as  in  Fig.  XXIII.,  called  pericorneal 
injection.  The  pain  is  worse  at  night  and  the  eye  is 
sensitive  to  touch,  especially  if  pressure  is  made  on  the 
upper  lid  of  the  closed  eye  just  back  of  the  limbus. 

Vision  is  impaired  and  there  is  some  loss  of  ac- 
commodation, lachrymation  and  photophobia  are,  as  in 
all  inflammatory  eye  troubles,  accompanying  symp- 
toms. 

The  iris  has  lost  its  lustre  and  has  a  muddy  ap- 
pearance; a  brown  iris  looks  yellow,  while  a  blue  one 
will  look  green. 

There  are  usually  posterior  synechia,  so  that  the 
pupil  does  not  dilate  evenly,  as  is  shown  in  Fig.  XXIV. 

There  are  three  diseases,  of  which  you  should  always 
remember  the  symptoms  and  never  mistake  one  fo^ 
the  other;  they  are  conjunctivitis,  iritis  and  glaucoma, 
and  I  trust  the  following  table  may  help  you  in  re- 
membering the  distinguishing  characteristics  of  each 
disease : 


CONJUNXTIVITIS. 

Pupil  regular. 

Pain  none,  except  the  burning  or  smart- 
ing, or  sensation  of  foreign  body,  feel- 
ing of  sand. 

Redness  general  over  the  enfcire  con- 
junctiva. 

More  or  less  discharge. 

Anterior  chamber  normal. 

Cornea  sensitive  to  touch  and  normal  in 
appearance. 

Pupil  normal  in  appearance. 
Tension  normal. 
Seen  at  any  age. 
Fundus  normal. 


ANn     now     RF.COCNIZEn. 


Iritis. 

Pupil  small,  contracted. 
Pain  severe,  worse  at  night,  in  eye  and 
over  brow. 

Redness  general,  but  more  intense  as  a 
ring  surrounding  the  cornea. 

No  discharge. 

Anterior  chamber  normal. 

Cornea  sensitive  to  touch  and  normal  in 
appearance. 

Pupil  muddj',  lacking  in  lustre. 
Tension  normal. 
Usually  under  45. 
Fundus  normal. 


Glaucoma. 
Pupil  dilated. 
Pain  comes  on  later  in  the  disease. 


May  resemble  either  one  or  both  of 
these  diseases. 

No  discharge. 

Anterior  chamber  shallow. 

Cornea  more  or  less  insensitive  to  touch 
and  less  transparent,  "steamed"  ap- 
pearance. 

Pupil  sluggish  and  may  appear  muddy. 

Tension  increased. 

Usually  past  middle  life. 

"Glaucomatous  cupping." 


44  DISEASES     OF     THE      EYE 

The  treatment  ot  iritis  depends  upon  the  cause; 
atropine  is  the  most  sedative  remedy  we  have;  band- 
age or  dark  glasses,  rest  and  constitutional  treatment, 
depending  on  the  cause. 

It  should  be  treated  as  early  as  possible  so  as  not  to 
endanger  the  sight  of  your  patient  and  to  prevent 
synechia  from  forming. 

One  of  the  most  characteristic  symptoms  is  the  zone 
of  inflammation  surrounding  the  cornea.  Notice  Fig. 
XXIII.  again;  notice  the  circle  or  zone  immediately 
around  the  cornea.  At  first  the  eyeball  is  only  red- 
dened ;  later,  as  the  disease  advances,  the  inflammation 
becomes  more  pronounced  and  the  circle  or  zone  just 
spoken  of  changes  from  a  pink  color  to  a  darker  red; 
this  is  called  the  peri-corneal  zone  or  zone  of  peri- 
corneal injection.  The  vessels  look  as  if  they  were 
about  to  creep  up  over  the  cornea. 


Diseases  of  the  Lens 


The  most  common,  as  well  as  the  most  frequent  dis- 
ease of  the  lens,  is  senile  cataract.  This  disease  comes 
on  in  old  life  and  is  accompanied  by  other  senile 
changes  in  the  body,  such  as  a  hardening-  of  the  blood 
vessels,  etc. 

The  patient  will  be  able  to  read  better  while  the 
cataract  is  forming  and  may  read  without  his  glasses, 
but  his  distant  vision  will  be  impaired.  This  is  due  to 
the  lens  becoming  more  convex  during  the  early  stages 
of  the  formation  of  the  cataract. 

The  patient  sees  better  on  a  cloudy  day  or  after  sun- 
down. 

Where  there  is  any  congestion  of  the  eyeball,  be 
sure  to  look  elsewhere  for  the  cause  of  such  conges- 
tion. A  cataract  does  not  cause  any  inflammation  of 
the  eye. 

This  disease  is  one  of  very  slow  progress,  and  the 
patient  may  not  be  aware  of  the  trouble  until  years 
after  the  formation  has  begun ;  he  will  probably  notice 
that  his  vision  has  become  impaired,  but  never  sus- 
pect the  cause. 

To  most  of  the  laity  a  cataract  means  a  white  growth 
or  scum  on  the  eyeball,  and  any  opacity  of  the  cornea 
or  even  a  pterigium  may  be  called  a  cataract  by  them. 
A  cataract  is  a  disease  of  the  crystalline  lens — an 
opacity  of  the  lens,  and  is  not  readily  noticed  until 
after  it  is  ripe. 


46  DISEASES     OF      THE      EYE 

The  vision  gradually  decreases  until  the  patient  can 
only  count  fingers,  and  eventually  he  loses  even  that 
much  visual  acuity.  One  or  both  eyes  may  be  affected 
at  the  same  time,  l^sually.  however,  one  eye  is  af- 
fected at  a  time,  or  the  disease  will  be  more  advanced 
in  one  than  in  the  other.  Both  eyes  are  always  sub- 
iccted  to  this  disease  sooner  or  later;  hence,  as  soon 
as  the  lens  in  one  eye  is  ripe,  the  cataract  should  be 
removed,  or  where  the  lenses  of  both  eyes  are  affected 
at  the  same  time,  the  lens  most  advanced  should  be 
needled  or  a  preliminary  irodcctomy  done,  so  as  to 
hasten  the  ripening. 


Fig.  XXV.— Puikije's  images;  x  from  the  cornea,  y  from  the 
anterior  surface  of  the  lens,  and  z  from  the  posterior  surface  of 
the  lens. 

Remember,  there  is  no  medicine  nor  any  form  of 
treatment  which  will  "absorb"  a  cataractous  lens ;  an 
opacity  of  the  cornea  can  be  "absorbed"  (?),  but  not 
a  cataract ;  so  warn  your  patients  that  they  are  not  only 
wasting  money,  but  that  the  delay  involved  while  fool  ■ 
ing  with  various  forms  of  fake  treatment  may  mean 
the  total  loss  of  vision. 


AND     HOW     RECOGNIZED.  47 

The  only  cure  for  cataract  is  extraction  of  the  lens, 
an  operation  requiring'  much  skill. 

Opacities  of  the  lens  can  be*  seen  by  oblique  illu- 
mination, as  is  shown  in  Fig.  XXII. 

When  a  lighted  candle  is  held  before  the  eye  and  a 
trifle  to  one  side,  you  will  notice  three  images,  called 
fhe  images  of  Purkinje,  as  shown  in  Fig.  XXV;  x 
is  the  bright,  upright  image  reflected  from  the  cornea ; 
y  is  an  enlarged  image  reflected  from  the  anterior  sur- 
face of  the  lens,  while  the  small  inverted  image,  z,  is 
reflected  from  the  posterior  surface  of  the  lens.  Fig. 
XXVI..  taken  from  Vol.  II.  of  the  American  Text 
Book  of  Physiology,  shows  the  method  in  which  these 
three  images  are  formed. 


,7  ,  ^r?-  ^XVl.— Method  of  forming  the  images  of  Purkinje.  From 
Vol  II.,  American  Text  Book  of  Physiology.  Also  explaining  accom- 
modation as  seen  with  the  Phakascope  of  Helmholtz;  a  is  the  corneal 
image;  b  is  the  image  formed  by  the  anterior  surface  of  the  lens,  and 
c  IS  the  image  formed  by  the  posterior  surface  of  the  lens;  (b'  show, 
the  change  in  the  image  from  the  position  of  b  during  accommodation). 


In  a  cataractous  lens,  z  is  absent  and  y  is  much 
dimmed,  depending  on  the  stage  of  the  disease;  x  is 
unaltered.  In  these  images  of  the  candle  flame,  x  and 
y  move  with  the  flame,  while  z  moves  in  the  opposite 
direction. 


48  DISF.ASRS     f)F     THE      EYE 

In  a  case  where  a  cataract  is  suspected,  a  mydriatic 
should  he  instilled  into  the  conjunctival  sac,  so  as  to 
have  a  clear  view  of  as  much  of  the  lens  as  is  possible. 
The  reflex  from  the  retinoscope  or  ophthalmoscope 
will  be  diminished  or  lost,  dependinj^  on  the  density  of 
the  opacity,  and  in  a  lens  in  which  the  disease  has 
|)rogrossed  very  far  it  will  be  impossible  to  see  the 
fundus. 

There  are  various  forms  of  cataract  which  you  will 
find  described  in  the  larger  works  on  diseases.  Perhaps 
one  of  the  forms  you  will  meet  with  quite  frequently 
is  wdiat  is  known  as  a  traumatic  cataract,  which  is  no 
more  than  an  opacity  of  the  lens  due  to  injury,  espe- 
cially frequent  in  cases  where  the  injury  has  pene- 
trated the  eyeball  and  the  lens  has  been  injured ;  often- 
times just  a  touch  by  the  foreign  body  will  be  sufficient 
to  start  the  formation  of  a  cataract. 


Glaucoma 


Glaucoma  is  a  disease  of  the  eye  in  which  the  canal 
of  Schlemm  is  blocked  up  and  the  fluids  of  the  eye 
are  dammed  up  so  that  they  do  not  drain  out,  causing 
marked  intraocular  pressure  with  degenerative  changes 
in  the  eye. 

Glaucoma  is  an  inflammatory  disease,  with  severe 
pain  and  congestion  of  the  eyeball,  much  like  that  of 
iritis.  There  is  loss  of  accommodative  power  and  tem- 
porary blurring  of  vision. 

It  usually  occurs  in  persons  past  middle  life ;  the  an- 
terior chamber  is  shallow  and  the  cornea  has  a  steamed 
appearance,  looks  as  if  it  had  been  breathed  upon,  and 
the  patient  will  complain  of  a  halo  or  ring  of  various 
colors  surrounding  lights.  The  pupil  is  dilated  and 
sluggish  and  the  anterior  chamber  is  shallow. 

Tlie  attacks  come  and  go,  each  attack  lasting  longer 
and  being  more  severe  than  the  preceding  one.  Glasses 
have  to  be  changed  frequently. 

The  vision  soon  becomes  permanently  impaired  and 
the  pain  becomes  more  or  less  constant,  is  quite  severe 
and  radiates  over  the  eye  and  temple,  the  patient  at 
first  often  mistaking  it  for  a  simple  attack  of  neuralgia. 

The  pain  soon  becomes  intense,  morphine  being 
about  the  only  thing  which  will  relieve  it,  and  the 
peri-corneal  inj;ection  is  marked. 

In  the  early  stages  determine  the  field  of  vision ;  it 
is  always  contracted,  especially  on  the  nasal  side,  and 
as  the  disease  advances  the  entire  field  becomes  con- 


r.O  DISEASES     OF     THE     EVE 

tractcd.  During  an  attack  the  tension  is  always  in- 
creased and  you  may  compare  it  with  the  hardnes- 
of  your  own  eye. 

Glaucoma  is  a  disease  which  requires  careful  study. 
and  to  make  a  diagnosis  in  the  incipient  stages  one 
must  be  careful  to  thoroughly  go  over  each  detail  to 
make  his  diagnosis  certain.  The  disease  may  be  pre- 
ceded by  premonitory  symptoms,  the  patient  feeling 
that  an  attack  is  coming  on  from  knowledge  of  past 
attacks,  and  where  the  history  points  to  previous 
attacks,  oftentimes  the  immediate  use  of  a  myotic 
will  postpone  or  abort  an  attack. 

This  disease  is  not  found  in  myopes. 

To  go  over  the  symptoms  again  I  will  tabulate  them 
so  that  they  may  be  more  easily  remembered:  i,  There 
is  the  pain  in  eye  and  over  brow,  "ciliary  neuralgia"" 
sometimes  called ;  2,  the  venous  congestion  and  ciliarv 
injection;  3,  dilatation  and  sluggishness  of  the  pupil; 
4,  increase  in  refraction  ;  5,  contraction  of  the  visual 
field,  dimness  of  vision,  halo  of  colors  and  scotomata ; 
6,  cloudiness  of  the  aqueous  and  vitreous  in  the  later 
stages  or  after  the  attack  is  well  developed,  and  the 
"breathed-on  appearance"  of  the  cornea ;  7,  anesthesia 
of  the  cornea  and  increased  tension ;  8,  cupping  of  the 
disk  with  pulsation  of  the  arteries  of  the  fundus. 

Fig.  XXVII.  shows  the  cupping  of  the  disk  is  glau- 
coma, and  Fig.  XXVIII.  shows  a  cross  section  of  the 
disk  which  explains  the  reason  for  the  disappearance 
of  the  vessels  over  tlie  edge  and  their  reappearance 
at  the  bottom  of  the  cup. 

There  is  a  physiological  cupping,  but  the  edges  are 
not  undermined,  and  the  vessels  are  visible  all  the  way 
down  to  the  bottom  of  the  cup. 

For  a  more  detailed  description  of  this  disease  I 
refer  you  to  some  of  the  standard  text  books  on  dis- 


AND     HOW     RECOGNIZED. 


eases  of  the  eye,  which  take  this  subject  up  iu  more 
detail. 


Fig.    XXVII 
scope. 


oplithalmo- 


Fig.  XXVIII.— Cross  .section  of  the  ilisk,  showing  reason  for  the 
disappearance  of  the  vessels  over  the  else  and  their  conseciuetit  re-an- 
pcarance   at    the   hottom   of   the  cup. 


52  niSKASF.S     OF    THE     EYE 

Other  diseases  which  involve  the  retina  can  be 
studied  from  the  text  books.  The  ones  which  the  op- 
tician should  be  able  to  recognize  are  some  of  the 
more  common  inflammations,  such  as  retinitis  albumin- 
urica,  retino-choroiditis  and  simple  congestion  of  the 
retina.  He  should  also  be  able  to  recognize  atrophy 
of  the  nerve,  detachments  of  the  retina,  interference 
willi  the  circulation  of  blood  in  the  retinal  vessels  and 
degenerative  changes  of  the  retinal  elements. 

"Haab's  Ophthalmoscopy,"  in  the  form  of  Saunder's 
Hand  Atlas,  is  perhaps  the  best  book  for  the  optician. 

We  have  now  considered  most  of  the  more  com- 
mon diseases  of  the  eye  with  which  you  are  likely 
to  meet. 

Injuries  are  of  so  rnany  forms  and  degrees  that  it 
would  be  impossible  to  undertake  a  description  of 
them. 

I  might  say  a  few  words  about  diseases  of  the 
lachrymal  apparatus,  as  it  forms  a  very  common 
disease. 

There  is  the  simple  closure  of  the  nasal  duct,  which 
causes  the  tears  to  flow  over  the  cheeks;  this  usually 
means  trouble  in  the  nose  and  the  patient  should  be 
referred  to  a  specialist  for  treatment  or  an  operation 
on  the  nose.  Quite  often  the  duct  is  closed  from  a 
stricUirc,  and  the  gradual  dilatation  by  probes  or 
sounds  will  effect  a  cure  without  any  operative  inter- 
ference in  the  nose.  This  method  of  treatment  is 
comparatively  painless,  and  a  few  treatments  usually 
effect  a  cure  unless  there  is  trouble  in  the  nose,  block- 
ing up  the  nasal  outlet  of  the  duct. 

If  there  has  been  any  interference  with  the  passage 
of  tears  down  the  nasal  duct  for  any  great  length  of 
time,  the  dilated  upper  portion  of  the  duct,  called  the 
sac,  may  become  infected   and   pus   form  in   the  sac, 


AND     HOW     RECOGNIZER  53 

which  causes  ^  bulging  of  the  skin  in  that  region  and 
may  swell  up  to  the  size  of  a  pigeon's  egg.  The  skin 
becomes  tense  and  somewhat  reddened ;  the  lower  lid 
is  swollen  partly  shut,  and  slight  pressure  over  the 
region  of  the  swelling  may  cause  a  drop  or  two  of 
pus  to  escape  through  the  lower  or  upper  punctum,  or 
both. 

Any  swelling  in  this  region  may  be  taken  to  mean 
a  diseased  condition  of  the  sac.  which  calls  for  prompt 
treatment. 


Fig.  XXIX. — Retention  of  tears  or  pus  in  the  lachrymal  sac,  causing 
a   swelling  in   that   region. 

Fig.  XXIX.  shows  the  swelHng  in  retention  of 
tears  or  blennorhoea  of  the  sac,  as  it  is  sometimes 
called,  and  if  the  contents  are  infected  the  term  dacryo- 
cystitis is  given  it. 

This  concludes  the  series  on  the  more  common  dis- 
eases of  the  eye,  and  I  trust  will  help  the  optician  in 
making  a  diagnosis  and  refer  his  patient  to  an  oculist 


54  DISEASES     OF     THE     EYE 

fur  early  treatment,  and  tliiis  raise  the  practice  of  op- 
tometry, so  that  it  will  be  looked  upon  as  a  profession 
and  not  a  business. 

The  optometrist  should  be  educated  to  the  highest 
point  of  efficiency.  He  now  surpasses  most  oculists 
and  "medical  refractionists"  in  his  knowledge  of  the 
optical  principles  involved  in  the  scientific  application 
of  lenses,  but  he  siiould  be  more  than  this ;  he  should 
know  anatomy  and  physiology  of  the  eye,  and  shouM 
be  able  to  recognize  the  more  common  diseases  of  the 
eye;  thus  would  he  surpass  the  family  doctor. 

He  should  be  able  to  handle  the  ophthalmoscope  in- 
telligently and  diagnose  the  more  frequent  pathological 
conditions  of  the  retina  and  nerve. 

I  hope  this  little  series  will  stimulate  you  to  the 
reading  more  of  diseases  of  the  eye  and  act  as  an  in- 
centive for  a  broader  knowledge  in  this  interesting 
field  of  study. 

Another  point  before  closing.  Read  your  trade 
journals — they  play  a  very  important  role  in  the  de- 
velopment of  American  business.  The  ideas  and  ex- 
periences of  others  are  at  your  disposal  through  their 
columns,  and  the  results  of  the  investigations  of  the 
optical  world  are  right  at  your  hand.  You  will  get 
suggestions  and  pointers  which  will  be  invaluable  to 
you. 

Your  trade  journals  put  you  in  touch  with  the 
thinkers,  with  men  who  plan  and  do  things,  and  it 
keeps  you  posted  as  to  what  is  going  on  in  your  pro- 
fession. With  optometry  laws  in  many  of  the  States 
(and  more  to  follow),  people  are  waking  up  to  the 
fact  that  the  practice  of  optometry  is  a  professional 
field,  and  not  one  of  pure  commercialism,  as  was  for- 
merly supposed.  In  illustrating  this  series  I  have 
had  the  able  assistance  of  Mr.  Poole.  I  also  desire  to 
thank   my   ofWcc  girl   for   many   poses   for  pictures. 


The  Eyes  of  School  Children 


The  Frequency  of  Refractive  Errors — The 
Value  of  Their  Detection  and  Correction — 
The  Influence  Upon  the  Mental  and  Physical 
Condition^ — The  Economic  Value  of  Vision 


The  Eyes  of  School  Children 


Ours  is  a  progressive  age  of  enlightenment.  Scien- 
tific men  the  world  over  are  giving  daily  to  the  world 
new  and  startling  discoveries.  Various  diseases  have 
been  studied  experimentally,  bringing  science  to  bear 
upon  the  alleviation  of  suffering  and  the  longevity  of 
the  race. 

And  yet  with  all  these  great  scientific  researches 
and  wonderful  achievements  by  men  of  science,  we  are 
only  now  awakening  to  the  fact  that  the  furtherance  of 
such  search  and  inquiry  into  unknown  fields  and  the 
solving  and  accomplishment  of  other  scientific  and 
business  problems  depends  on  the  development  and 
health  of  the  coming  generation — the  school  children 
of  to-day. 

This  city  (Spokane)  has  started  this  year  aright 
with  the  examination  of  its  school  children  by  special- 
ists, who  devote  their  time  to  the  searching  out  of  any 
diseased  or  defective  children,  educating  both  pupils 
and  teachers  in  school  hygeine  and  throwing  out  safe- 
guards for  the  protection  of  life  against  disease,  that 
the  future  of  this  city  may  be  preserved  in  the  devel- 
opment of  a  healthy  lot  of  boys  and  girls. 

There  are  two  of  the  special  senses  which,  when  de- 
fective, greatly  modify  the  physical  as  well  as  the 
mental  development  of  a  child— seeing  and  hearing. 
Since  the  former  is  the  more  important  and  its  defects 


AND     now     RECOGNIZED.  57 

the  most  frequent,  I  shall  consider  it  in  this  brief 
paper.  It  will  be  my  purpose  in  this  contribution  to 
give  such  information  as  will,  I  trust,  convey  the 
manner  in  which  the  eyes  can  and  do  affect  the  mind 
as  well  as  the  body ;  to  demonstrate  how  the  results  of 
unrecognized  and  uncorrected  defects  of  the  eyes  and 


o.S2§8gSSssSgS.esSS§S3 


Table   showing   refractive   errors   and   percentages   at   different   ages   of 
school  life. 


II.   Curve   of   myopia. 


I.    Curve   of   emmetropia. 
schools. 

III.   Curve   of   emmetropia.      IV.    Curve    of   hypermetropi 
of  myopia.     Erismann — St.   Petersburg. 

VI.   Curve  of  hypermetropia.      Risley — Philadelphia. 


Risley— Philadelphia 
v.    Curve 


anomilies  of  the  extra-ocular  muscles  do  create  and 
perpetuate  nervous,  physical  and  mental  derangements. 

The  results  of  the  examinations  of  over  two  hun- 
dred thousand  school  children  of  all  grades,  by  Euro- 
pean and  American  observers,  furnish  the  data  from 
which  the  statistics  regarding  the  frequency  of  refrac- 
tive errors  have  been  compiled. 

From  Fig.  i  it  will  be  seen  that  emmetropia  remains 


r.8  niSEASF.S     OF    TTIK     EVE 

almost  constant  in  the  various  ages,  while  hypermc- 
tropia  gradually  decreases  among  the  school  children 
in  the  higher  grades,  while  the  percentage  of  myopia 
increases  in  the  more  advanced  classes. 

The  percentages  are  shown  diagrammatically  by 
curves;  notice  the  curve  of  myopia  (2);  at  the  age 
of  eight  and  a  half  years  there  was  found  only  4.27 
per  cent.;  after  that  age  there  is  a  gradual  increase 
until  at  the  age  of  seventeen  and  a  half  years  it  has 
reached  19.33  P^^  cent. 

Curve  of  myopia   (5),  from  Erismann's  examina- 


2  OymnasiuBS 


Figure  II.  Showing  increase  in  percentage  of  myopia  in  the  higlier 
grades,  in  direct  proportion  to  the  length  of  time  devoted  to  school  life. 
Made  from  Cohn's  statistics. 

tions  of  the  school  children  of  St.  Petersburg,  shows 
a  much  larger  percentage  of  myopes,  ranging  from 
18.C  per  cent,  in  the  young  children  up  to  42.8  per 
cent,  in  the  more  advanced  classes,  up  to  the  age  of 
thirteen,  against  the  19.33  P^r  cent,  at  the  age  of  seven- 
teen and  a  half  years  in  the  Philadelphia  schools. 

Risley  found  36.2  per  cent,  of  hyperopia  in  the 
Philadelphia  schools,  whereas  Erismann  found  66.84 
per  cent,  in  the  St.  Petersburg  schools. 


AND     now     RECOGNIZED.  59 

Colin  examined  the  eyes  of  ten  thousand  and  sixty 
school  children  in  Breslau  and  vicinity,  and  Fig.  2 
shows,  diagrammatically,  his  findings. 

There  is  the  same  increase  of  myopia  from  the 
lowest  to  the  highest  grades ;  in  the  primary  grades 
only  1.4  per  cent,  were  myopic,  while  in  the  gymna- 
siums the  percentage  of  myopia  had  increased  to  26.2 
per  cent. 

From  these  tables  of  results  we  may  very  properly 
conclude  that  this  increase  of  myopia  is  due  in  direct 
proportion  to  the  length  of  time  devoted  to  school  life 
— the  length  of  time  the  child  has  been  subjected  to 
eye  strain.  This  continuous  progression  of  myopia 
has  been  verified  by  numerous  observers  in  this  coun- 
try, as  shown  by  Risley's  arrangement  of  Randall's 
tables,  page  357  of  Norris  &  Oliver,  Vol.  2. 

While  the  percentage  of  myopia  among  the  ad- 
vanced students  is  not  nearly  so  great  in  America  as 
in  Europe,  yet  the  same  significant  fact  confronts  us : 
myopia  is  on  the  increase. 

Most  children  start  to  school  between  the  ages  of 
five  and  six,  at  an  age  when  the  eyes  are  not  fully  de- 
veloped, no  more  than  the  remainder  of  the  body,  and 
it  is  by  no  means  equal  to  the  tax  imposed  upon  it  by 
constant  use  in  study. 

The  refractive  condition  of  the  eye  in  early  child- 
hood is  nearly  as  often  hyperopic  as  it  is  emmetropic, 
and  the  strain  upon  accommodation  as  well  as  upon 
convergence  is  greater  than  evolution  has  provided  for. 

A  child,  unlike  an  adult  who  reads  a  line  or  sentence 
at  a  glance  by  comprehending  the  general  appearance 
and  arrangement  of  the  letters,  has  to  study  each  letter 
of  every  separate  word,  just  as  an  adult  would  have 
to  do  in  reading  an  unfamiliar  foreign  language.  Now 
if  the  eye  be  hyperopic,  as  the  large  percentage  usually 


60  DISEASES     OF    THE     EYE 

arc,  it  means  an  increased  amount  of  accommodation  is 
called  into  use. 

The  internal  recti  and  the  ciliary  muscles  normally 
act  together,  the  recti  turning  the  eyes  in  one  metre 
angle  for  each  dioptre  of  accommodation. 

An  emmetropic  eye  is  absolutely  passive  in  looking 
at  infinity:  objects  20  feet  or  more  away;  anything 
closer  than  this  is  focused  by  the  action  of  the  ciliary 
muscle,  and  at  the  same  time  binocular  vision  is  main- 
tained by  the  action  of  the  internal  recti. 

If  the  child  is  hyperopic,  the  eye  is  never  passive; 
it  must  accommodate  for  distance  as  well  as  for  near 
obj.ects,  hence  it  does  not  have  a  chance  to  rest;  not 
only  is  the  accommodation  working  overtime,  but  there 
is  the  unconscious  act  of  convergence  with  it,  paral- 
lelism of  the  visual  axes  being  maintained  by  action 
of  the  external  recti — more  abnormal  expenditure  of 
muscular  efforc  with  the  dissipation  of  nervous  energy. 

In  reading,  the  strain  is  even  greater  than  for  dis- 
tance, since  there  will  be  more  meter  angles  of  con- 
vergence than  is  required  for  the  distance  at  which 
the  child  is  reading. 

This  extra  strain  will  not  be  long  tolerated,  if  the 
refi-active  error  amounts  to  considerable,  as  the  child 
will  "fix"  with  one  eye  and  allow  the  other  to  deviate, 
with  the  resulting  "squint"  or  "cross-eyes." 

On  the  other  hand,  if  the  child  is  myopic  he  will  be 
unable  to  see  distinctly  at  a  distance  and  will  prefer 
study  to  outdoor  play;  but  here  the  strai-n  is  not  so 
great  and  does  not  produce  the  nervous  and  physical 
derangements  that  hyperopia  does;  the  danger  in  my- 
opia lies  in  the  development  of  "progressive  myopia  ' — 
a  very  serious  condition. 

Myopes  are  referred  to  the  specialist  more  often 
than  arc  hyperopes,  as  a  myopic  child  is  usually  con- 


AND     HOW     RECOGNIZED.  61 

scious  of  his  defect  or  very  soon  manifests  it  by  his 
poor  sight  for  distant  objects — across  th^  room  or  the 
blackboard. 

Low  degrees  of  "near-sightedness"  are  not  as  a  rule 
noticed,  and  the  child  may  be  conscious  that  his  eyes 
are  not  normal ;  these  cases  are  by  no  means  rare  and 
are  the  result  of  the  constant  strain  upon  the  eye  and 
its  appendages. 

Eye  strain  is  the  forerunner  of  myopia,  and  it  is 
unreasonable  to  conclude  that  the  myopic  eye  is  along 
the  lines  of  normal  development,  but  rather  a  disease. 
Souter  thinks  the  change  from  hyperopia  or  emme- 
tropia  to  myopia  is  not  of  any  serious  consequence  in 
the  average  case.  He  says :  "In  the  natural  course 
of  growth  there  occurs  an  enlargement  of  the  eyes 
with  the  consequent  diminution  of  hyperopia,  and 
normally  hyperopia  passes  into  emmetropia  before 
adult  life.  But  in  a  certain  proportion  of  cases  the 
increase  in  axial  length  is  not  arrested  when  emme- 
tropia is  reached,  and  a  condition  of  myopia  results. 
This  is  probably  caused  by  stretching  the  sclera  by 
muscular  pressure  and  traction  in  the  convergence 
required  in  school  work.  This  kind  of  myopia  does 
not  reach  a  very  high  degree,  and  it  ceases  to  advance 
after  the  sclera  has  acquired  its  normal  resisting  power 
in  adult  life.  It  is,  therefore,  called  benign  or  school 
myopia." 

The  general  concensus  of  opinion  is  that  myopia  al- 
most invariably  follows  eye  strain,  usually  coming  on 
after  the  eighth  year,  and  can  be  attributed  to  faulty 
position  of  the  desks  or  seats,  holding  work  too  close, 
insufficient  or  improper  light,  etc.  Myopia  is  never 
congenital,  but  may  be  inherited,  since  myopic  parents 
are  apt  to  have  myopic  children ;  and  as  Ball  says, 
"Just   as  the  susceptibility  to  tuberculosis   is  passed 


G2  DISEASES     Or     THE     EYE 

from  parent  to  child,  so  may  the  tendency  to  myopia 
be  inherited."  He  further  states  that  myopia  is  just 
as  truly  a  disease  as  is  tuberculosis,  since  there  is  the 
same  tendency  to  develop  myopia  as  there  is  to  con- 
tract tuberculosis  under  the  proper  conditions  favor- 
able to  its  development. 

From  a  careful  study  of  this  disease  the  conclusion 
seems  inevitable  that  the  strain  of  constant  work  at 
the  near  point  is  the  cause  of  myopia,  and  that  this 
cause  is  more  potent  during  the  growing  period — the 
school  life — of  the  child. 

Whenever  a  child  in  apparently  good  health  discards 
outdoor  play  for  reading,  it  is  generally  due,  not  as 
some  people  like  to  suppose  to  the  child  being  pre- 
cocious, but  to  "near-sightedness." 

Much  time  end  study  has  been  spent  in  the  hygiene 
of  school  rooms,  the  lighting,  printing  of  books, 
spacing  of  the  letters,  the  width  of  the  pages,  size  and 
leading  of  the  type,  and  other  changes.  The  vertical 
system  of  writing  has  been  introduced,  and  more  time 
is  given  to  blackboard  exercises  and  to  oral  instruc- 
tion, while  the  amount  of  "night  work"  required  is 
much  less  than  formerly. 

And  while  all  the  advances  have  had  the  endorse- 
ment of  all  intelligent  persons,  yet  the  disappointing 
fact  still  remains — there  is  much  uncorrected  eye 
strain  among  school  children  which  will  eventually 
result  in  myopia. 

"Far-sighted"  children,  on  the  other  hand,  have  re- 
markably acute  vision,  and  usually  excel  in  outdoor 
sports.  Study  to  them  is  irksome  and  reading  a  bur- 
den, and  these  are  the  very  cases  that  are  seldom  given 
the  early  attention  which  they  should  by  all  means 
have. 

Parents  and  toarhers  wi'l  tell  you  of  the  child's  keen 


AND     now     RECOGNIZED.  63 

sight,  being  able  to  distinguish  small  objects  which 
they  themselves  are  unable  to  see,  and  because  the 
child  can  read  20/20  it  is  oftentimes  difficult  to  per- 
suade them  that  the  child  is  sufferinof  from  eye  strain 
and  needs  the  attention  of  a  competent  refractionist. 

It  is  not  because  the  child  is  lazy  that  he  prefers  out- 
door sports  to  study,  but  because  of  his  defective  eyes 
play  and  outdoor  life  gives  to  his  eyes  a  grateful  feel- 
ing of  relief  and  comfort,  while  study  brings  on  a 
headache  or  other  symptoms  of  asthenopia  due  to 
ocular  strain. 

The  old-time  idea  "that  to  put  glasses  on  young 
children  so  weakens  their  eyes  that  they  cannot  get 
rid  of  the  habit  of  wearing  them,"  is  entirely  errone- 
ous and  due  to  ignorance  on  the  part  of  parents,  teach- 
ers and  friends.  Glasses  relieve  the  trouble  and  tend 
to  make  a  perfect  eye  of  an  imperfect  one,  with  the 
result  that  the  child  prefers  not  to  do  without  his 
glasses ;  has  no  desire  to  have  imperfect  eyes  again 
with  all  the  attendant  troubles ;  and  because  he  wants 
that  which  gives  him  comfort,  the  lay  person  is  apt 
to  think  that  he  has  "weakened"  his  eyes  to  such  an 
extent  that  he  can  no  longer  get  along  without  the 
aid  of  glasses. 

Eye  strain  means  nerve  drain.  It  requires  a  stimu- 
lus to  make  muscular  fibres  contract,  and  this  stimulus 
is  nerve  enegry. 

A  hyperopic  eye  is  always  active ;  never  passive, 
never  at  rest;  constantly  using  up  nervous  energy  from 
the  time  the  eyes  are  opened  in  the  morning  until  they 
are  closed  in  sleep  at  night ;  constantly  receiving  visual 
impressions  of  some  kind,  even  unconsciously;  yet 
these  pictures  must  be  accurately  focused,  as  near  so 
as  is  possible  with  the  defective  eye,  for  the  brain  will 
not  long  tolerate  a  blurred  picture  without  producing 


';i  mSEASKS     OF    THE     EYE 

nausea  or  astlicnopia.  In  other  words,  an  eye  of  this 
kind  is  using  more  than  its  normal  supply  of  nerve 
energy. 

The  effects  of  this  incessant  drawing  upon  the  brain's 
storehouse  is  soon  manifested  by  various  disturbances 
of  the  nervous  system,  for  any  excessive  or  abnormal 
expenditure  of  nervous  energy  to  any  one  particular 
organ  is  furnished  at  the  expense  of  others  sooner  or 
later. 

Not  always  is  this  constant  drain  upon  the  nervous 
system  manifested  through  the  eyes,  but  more  often 
through  reflex  disturbances  of  the  body,  sleeplessness, 
headaches,  indigestion,  chorea,  inability  "to  fix  at- 
tention," and  other  various  nervous  and  mental  dis- 
orders. 

That  eye  strain  is  a  potent  factor  in  the  causation 
of  many  nervous  and  physical  disorders  is  substanti- 
ated by  an  abundance  of  clinical  data,  and  is  cited  as 
an  etiological  factor  by  many  neurologists  in  works 
on  diseases  of  the  nervous  system. 

Imbalance  of  the  extra-ocular  muscles  always  fol- 
lows simple  hyperopia  or  hyperopic  astigmatism  and 
greatly  adds  to  the  already  large  burden  upon  the  brain 
and  should  be  looked  for  in  every  case  of  refraction 
among  children,  and  if  found  to  be  of  any  large  de- 
gree should  be  restored  to  their  normal  equilibrium 
by  muscular  gymnastics  and  not  by  the  use  of  prisms. 

Twenty-six  to  forty  per  cent,  of  school  children  have 
refractive  errors  of  enough  magnitude  to  be  corrected ; 
errors  that  demand  correction  early  in  life,  for  the 
strain  resulting  from  these  high  errors  in  time  pro- 
duces a  nervous  irritability  which  is  analogous  to 
nervous  prostration  in  adults. 

In  drawing  conclusions  we  should  remember  that 
tlie  eyes  of  the  Indians,  Patagonians,  Laplanders,  the 


AND     now     RECOGNIZED.  65 

peasant  classes  of  Europe,  and  among  the  farmers  of 
this  country,  do  not  become  myopic,  nor  do  others  who 
follow  outdoor  life  have  myopia ;  only  those  whose  em- 
ployment of  the  eyes  at  close  range  ever  suffer  from 
myopia  and  other  refractive  troubles. 

Since  the  negro  has  been  freed  from  slavery  and 
has  taken  up  the  white  man's  ways  of  living  and  is 
devoting  some  time  to  study,  myopia  has  begun  to 
appear  among  that  race. 

Another  point  to  remember  in  closing  is  the  fact  that 
the  change  from  hyperopia  to  myopia  is  accompanied 
by  a  train  of  pathological  symptoms,  such  as  head- 
aches, painful  eyes,  undue  sensitiveness  to  light,  in- 
creased lachrymation  and  impairment  of  vision,  all  of 
which  are  aggravated  by  work  at  the  near  point  and 
subside  upon  rest  of  the  eyes,  but  reoccur  as  soon  as 
work  is  resumed. 

There  is  almost  always  spasm  of  the  accommodation, 
more  or  less  retinitis  and  choroiditis,  with  congestion 
of  the  eyeballs. 

If  this  condition  persists  for  any  length  of  time  un- 
corrected, there  is  an  increased  refraction  of  the  eye. 

This  process  is  by  no  means  a  physiological  one  and 
is  far  from  being  along  evolutionary  lines ;  it  is,  there- 
fore, obvious  that  these  symptoms  are  but  the  fore- 
runners of  a  stretching  of  the  ocular  coats  with  in- 
creased axial  length  in  the  antero-posterior  diameter 
of  the  eye  with  consequent  staphyloma  of  the  pro- 
gressive myopic  eye. 

We  have  improved  the  hygienic  conditions  of  the 
school  room,  have  given  attention  to  the  books,  etc. ; 
now  come  the  questions,  "How  are  we  to  get  at  these 
cases  and  give  them  the  treatment  they  require  ?  How 
can  the  tests  be  made  on  so  large  a  scale?" 

The  teacher  could  at  the  beginning  of  each  school 


«6  DISEASES     OF     THE     EYE 

year  make  tests  at  20  feet  with  a  specially  prepared 
test  type,  testings  each  eye  separately,  and  if  the  vision 
in  either  eye  fell  below  20/20  she  should  make  note 
of  the  fact  and  have  the  child  consult  a  competent 
oculist  or  optician.  She  should  also  note  whether  or 
not  the  eyes  are  inflamed,  what  trouble  the  child  com- 
plains of,  headaches  or  eye  pain,  and  the  frequency 
of  the  symptoms  of  eye  strain. 

V,i,.J-T?.»<,r£y*    /T|0  ^eAo-<o,t    *d(>«'      W«.,.   tV-e^  ju«.^L,X.«_ 

£^/v  *«    j»f  T»<#  Sm^e   OifriM<.f>.f?  ^^LC.-^     "^   . 

0»BS  He  wefn6^»ti£.i'>  A't^ 

fl^r    o  HS.K  tnut  Puct  mn^i'?         J^^^     • 


By  keeping  a  record  of  such  cases  on  a  small  card 
such  as  is  shown  in  Fig.  3  would  enable  the  teacher  to 
co-operate  with  the  specialist  and  aid  very  materially 
in  rapid  work  of  examination. 

Teachers  should  be  instructed  to  advise  the  child  of 
any  faulty  position  of  the  head  or  book  and  should 
so  seat  the  pupils  as  to  get  the  proper  height  of  desk 
and  seat  for  each  individual  student. 

Ordinarily  children  should  not  enter  school  before 
the  age  of  eight  years,  and  should  do  no  outside  read- 


AND    HOW     RECOGNIZED.  67 

ing  or  studying  until  the  age  of  eleven.  The  habit  of 
reading  novels  and  stories  of  exciting  adventure  should 
be  discour-aged ;  books  should  be  interesting  enough  to 
hold  the  child's  attention  without  effort,  but  should 
not  be  of  such  nature  as  to  cause  excitement  and  over- 
stimulation of  the  accommodative  apparatus. 

The  examination  of  children's  eyes  should  be  a  part 
of  the  routine  duty  of  the  teachers  or  the  physicians 
making  the  medical  examination  of  the  schools,  as  it 
may  mean  the  saving  of  several  pairs  of  eyes  each 
year,  and  will  enable  the  child  who  has  refractive 
errors  to  do  better  work. 

As  to  the  economic  value  of  vision,  we  have  no 
basis  for  the  value  of  vision  from  a  scientific  stand- 
point; it  is  a  supposition  generally  accepted  that  a 
blind  person  is  totally  incapacitated  for  work  in  any 
of  the  trades  or  professions. 

Vision  is  the  principal  factor  considered  in  any  vo- 
cation, for  upon  one's  ability  to  see  and  see  well  de- 
pends his  chance  for  securing  employment.  Persons 
mentally  deficient  cannot  be  considered,  since  they  play 
very  little  or  no  part  in  social  economics,  except  as  a 
source  of  drain  upon  the  revenue  resulting  from  direct 
taxation.  The  loss  of  the  sense  of  hearing  does  not 
debar  one  from  entering  upon  certain  occupations,  nor 
does  the  loss  of  an  arm  or  leg  exclude  one  from  a 
gainful  calling,  but  the  loss  of  only  one  eye  will  often- 
times prevent  one  from  many  forms  of  livelihood. 

The  value  of  eyesight  has  not  been  estimated  from 
a  financial  standpoint,  it  being  the  rule  to  value  it  ac- 
cording to  the  earning  capacity  at  the  time  of  injury; 
the  various  accident  companies  place  the  value  of  one 
eye  from  one  to  five  thousand  dollars,  while  loss  of 
vision  of  both  eyes  is  usually  placed  at  about  triple 
that  amount. 


68  DISEASES     OF     THE     EVE 

Railroad  employees  are  required  to  have  good  vision, 
likewise  the  men  of  the  army  and  navy,  and  in  many 
other  vocations  good  vision  is  absolutely  essential. 

Partial  loss  of  vision  of  one  or  both  eyes  is  not  con- 
sidered, from  a  financial  point  of  view,  to  be  of  any 
serious  consequences,  yet  it  prohibits  one  from  enter- 
ing nearly  all  occupations,  yet  it  is  not,  as  a  rule,  con- 
sidered by  the  insurance  companies. 

We  may  in  time  get  at  the  true  economic  value  of 
vision  from  a  scientific  standpoint,  but  as  yet  we  are 
far  from  it,  the  value  being  placed  at  about  half  the 
loss  of  earning  power. 


ALL  THERE  IS  TO  BE  KNOWN  ABOUT 

THE  ANATOMY  OF  THE  HUMAN  EYE 

IS  TO  BE  FOUND  IN  OUR 

Manikin  of  the  Human  Eye 

04  Parts,  in  colors  of  nature,  so  you  can  see  and 
handle  tlieni 


Comprehensive  Text  Book,  all  complete,  for  $1.00  per  copy 


FREDERICK  BOQER  PUB.  CO.,  1  Maiden  Lane.N.  Y. 


o 
o 


u 


O 
O 

I 

u 
O 

H 


S   3 


lit 


•2  u- " 

O.S   s 


«  0 

i 

u 

-O    O 


|o  si 


i  « 

io 


O  c/3 

■5 


I    •  21^ 


-a     c    o   c   L» 


u  -   o     o 


3      S)  ' 


l-S  ^ 

(b'o   f 


U    o 

ii 


"    c 

I" 

E  = 


I      g 

O    a 


J  E 


3 


^  "5  H     O      00^ 


»  2   o 

O  E   =   c 


on 


-0: 


;3B 

«3 


^.sf 


tfl  t  ., 


I^J 


3     C 


|-  1-1 


V  2 
c  .2- 


Transpositions 

A    CLEAR    EXPLANATION    OF 
AN      OPTICAL      DIFFICULTY 


32  Pages  and  39  Diagrams   by 
R.  M.  LOCKWOOD 


PRICE    25     CENTS 


"Bhe  Frederick  Bo^er  Publishing  Co. 
1  Maiden  Lane         ::         ::        New  York 


Tried  *"«*  True 

BIGGER,    BRIGHTER 
BETTER     THAN     EVER 

Always  good,  but  never  so  good  a.9  now 


5,000  paid  subscribers.  15,000  readers, 
comprising  all  live  and  progressive  deal- 
ers in  opti-al  goods  and  practitioners  in 
optometry. 

No  schemes  or  special  numbers.  The  Optical 
Journal  comes  out  once  a  week,  the  first  issue  of 
each  month  being  a  large  magazine. 

Vou  may  advertise  in  your  own  time  and  way," 
being  assured  th'at  in  the  pages  of  The  Optical 
Journal  you  get  the  widest  possible  circulation 
among  people  who  are  interested  in  optics..' 


Frederick    Boger    P\ib.    Co. 

1  Matden  Lane.  New  Vork 


Encyclopedic  Optical  Dictionary 


By  JAS.  J.  LEWIS,  Oph.  D. 


1 

( 

60                                    LEWIS  POCKET 

\ 

OPniCAL  DICTIONARY                               01 

ll 

hotter  than  that  o(  eserine.  and  does  not  act  aa 

-r 

Eiotrepla  (ex-o-tro'-pl-nh).     When  the  eye  is  turned 

powerfully  aa  the  latter,  but  is  not  accompanii-d 

1 

outward  from  parallelism.     Divergent  strabismus. 

M     any    unpleasant    complications      E.erlne    .s 

Exirartlon  (ex-lrak'-shun).     The  removal  of  a  body 

i 

1      1  r<  served  loi  those  cases  in  which  pilocarpine 
mifTcctual. 

by  surgical  means. 

( 

vi:;' 

•^^^^^^V 

1,   dtMatt  inward,  usually  caused  by  hyperopia. 

^^daHHJI^^Nv 

I^.lropla    (c-so-tro'-pi-ahV  'This  term  expresses   a 

1 

y^fl^^^^l^^Brvx 

iiurii;.  r  niraninR  than  Esophoria.  in  which  there 

l^^^fjfl^^^^^^^^^^^H^VV 

,. 

1,  imnly  a  tendency,  while  in  Esotropia  there  is 

:| 

i^KiS^^^^^^^^^^^^^CJvK. 

," 

a   po^tive   and    visible  appearance   of    the   eyes 

HRgs^^^^^H^^^^^^HhttlkX 

,''5jl 

luriung  inward 

ti,: 

^m^^BB^u^HKM  \flk\ 

•  'ifm 

nicataUoD  (cx-cav-a'-shun).     Excavation  of  optic 

i' 

jJBWWHHwB||B|^»     '  fSbX 

'aI 

nerve,  cupping  or  hollowing  of  the  optic  disc. 

'llwr^^^^^SB      '  1  5 

IjnH 

Eiophorla  (ex-o-fo'-ri-ah)      A  tendency  of  the  eyo 

iVf             B^  A'#/ 

'Mi 

to  deviate  outward 

r, 

M 

Exophthalmic  Goiter  (eks-off-thal-mik  goi'tcr).     A 

Vvt          '^spW/ 

Ft 

V>^                  jn^B^Jr 

Basedow's    disease;  Graves'   disease.     The    most 

!•' 

>(Vlt^                -^^^mW/ 

prominent  symptoms  are  protrusion  of   the  eye. 

1 

i^^^^it^      ^n^R^ 

excited   action    of   the  heart,    enlarged    thyroaf 

1 

^^SS^S^sB^i^ 

(goiter),  and   certain  nervous  phenomena.     The 

r'li 

^"^^^^^^^^I!!^^ 

1? 

Em 

not  infrequently  greater  on  the  right  side      The 
upper  hds  do  not  follow  the  eyeball  in  looking 

li'i' 

Eye.    The  organ  of  sight.     The  function  of  each 

down  (Von  Graefe'a  sign),  infrequcncy  of  involun- 
tary  winking    (Stellwag's    sign)    and    abnormal 
width  of  the  palpebral  aperture  are  also  found. 

eye,  taken  singly,  is  to  form  upon  the  retina,  or 
nervous   membrane   which   lines   the   Inside   and 
back  part  of  the  organ,  a  sharply  defined  inverted 
image  of  any  object  looked  at.    The  eye  resembles 

a  photographer's  camera,  inasmuch  as  the  image 

produced  upon  the  retina  is  precisely  the  same  as 
that  produced  on  the  ground  glass  of  a  camera. 

EioiTHUim.     Protrusion  of  the  eyeball. 

ill 

By  means  of  the  optic  nerve  the  image  that  is 
received  on  the  retina  is  conveyed  to  the  brain, 

ONE-HALF  THE  ORIUINAL  SIZE 

SOME  OF  THE  GOOD  POINTS 

A  complete  dictionary  of  the  terms  used  in  Optometry  and  Ophtlialmometry. 
A  clear  presentation  of  the  wave  theory  of  light  with  plates 
A  concise  yet  thorough  explanation  of  the  Anatomy.  Fuuctiond  a 
Practical  hints,  things  to  be  remembered  and  questions  and  ans 
State  examinations. 

Price  $1.25,  Postage  Prepaid 

F.  BOQER   PUBLISHING   CO.,    l  Maiden  Lane,  New  York 


DICTIONARY    OF 
OPHTHALMIC  TERMS 

By  JOHN  WELSH  CROSKEV,  M.D. 

Ophthalmic  Surgeon  to  the  Philadelphia 
Hospital  and  the  George  Nugent 
Home  for  Baptists;  Consulting 
Ophthalmologist  to  the  Prince  of 
Peace  Hospital,  Philadelphia. 

Contains  all  those  ophthalmological 
words  that  are  scattered  throughout 
the  ordinary  medical  dictionaries. 
Print  is  clear  and  definitions  con- 
cise. The  use  of  the  book  will 
save  a  great  deal  of  time  to  all 
students  ot  ophthalmology. 

80  pages,  including  supplement, 
giving  useful  optometrical  infor- 
mation. 

In    pasteboard,    price  25    cents 
In  limp  leather,  price  50  cents 


Frederick    Boger    Publishing   Co. 

1   MAIDEN  LANE,  NEW  YORK 


OpticioLns* 
Ma-nual 

Advertising 


It  is  the  most  novel  and  complete 
exposition  of  the  art  of  advertising 
from  the  viewpoint  of  the  optician 
that  has  ever  been  published.  There 
are  some  fifteen  chapters,  covering 
the  subject  from  A  to  Z,  and  the 
book  is  profusely  illustrated  with 
examples  of  optical  advertising. 

The  pages  are  size  9  by  12  inches. 
Price  in  hea'by  paper  cohers,  SO  cents, 
postage  prepaid. 

Every  optician  who  believes  in 
advertising  and  every  one  who  does 
not  should  buy  and  study  this  book. 


Frederick  Bo^er  P\ib.  Co. 

One  Maiden  Lane,   New  York  City 


The  Legal  Secretary 

The  Latest  Work  on  Commercial  Law  and 

Business  Usage. 

Devoted  to  the  interests  of  the  Optical  and 

kindred  professions. 

BY 

WILLIAM  V.  MOORE 

Patent  rights  and  the  infringement  of  these 
rights  is  a  subject  of  present  importance  to  op- 
ticians. 

And  yet  but  few  seem  to  have  the  remotest 
idea  of  the  principles  underlying  this  source  of 
so  much  legal  strife  among  business  men,  or  the 
laws  to  which  these  principles  have  been  applied. 
The  author  of  this  work  clearly  and  concisely 
explains  the  whole  system.  Patent  Law,  Trade- 
Marks,  Prints  and  Labels,  and  the  law  of  Copy- 
right.   

$3.00— SENT  POSTPAID  FOR  $3.00 


FREDERICK  BOGER  PUBLISHING  CO. 

1  M»id«n  Lane.  NEW  YORK 


(•^ 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BO^OWED 

This  book  is  due  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 

■Renewed  books  are  subject  to  immediate  recall. 


/-/<^-?7- 


1 


^' 


LD  21-50wi-4,'63 
(D6471sl0)476 


General  Library 

University  of  California 

Berkeley 


